Episode 5: THE MOUNTAIN

Empowered Sleep Apnea: THE PODCAST
Season Finale
Episode 5: THE MOUNTAIN
All content © 2022 Empowered Sleep Apnea, LLC
www.EmpoweredSleepApnea.com

For a PDF Transcript of this Podcast, including links to cartoons and whatnot, click HERE!

A lone crow...a hidden key...another traveler...a place full of Mountain Magic...

After crossing the RIVER OF DECISION over to TREATED TERRITORY, Robert's gonna find out the reason for that ol' ISLAND SAYING: It's not the crossing, it's the landing!

Many things can go wrong, you see...on your way to Pleasant Dreams Beach.

In this special Season Finale episode, our ol' pal Robert will discover that orienteering around the ISLE is going to require an...um...elevated approach (tee-hee!)...along with...a different set of eyes, a ghost, and an engineering mindset.

In this exceptional, empowering, exciting and vastly entertaining episode, you will...
1. ...take a personal tour of an expert-level Sleep Medicine clinical problem-solving tool  called The Five Finger Approach
2. ...look "under the hood" of the Sleep-Wake MACHINE called the TWO-PROCESS MODEL of Sleep-Wake Regulation
3. ...dig deep into the concept of Circadian Misalignment, using a neato and fully RAD biologic decoder-ring GIZMO called the Circadian Rhythmo-Wheel!
4. ...do a head-first deep-dive into a common complication of Sleep Apnea management called Treatment Emergent Central Sleep Apnea (TECSA), and learn what to do about it from somebody with a ton of experience: Altitude Sleep Medicine expert, Dr. Tom Minor!

Special Guests:
The part of Annie played by Ms. LeVette Fuller
Dr. Tom Minor, as himself

Featured Cartoons & Links:
1. Common Substances that Affect Sleep and Wake (excerpt from our Beautiful Blue Book)
2. Circadian Rhythmo-Wheel , a PDF for printing and assembly at home! (also an excerpt from said Beautiful Blue Book.
3. Fumes in the Attic -- a cartoon to explain the concept of homeostatic sleep pressure and the function of the glymphatic system.
4. Five Finger Approach publication
5. American Academy of Sleep Medicine (AASM) Two Week Sleep Diary

Our Website: https://www.empoweredsleepapnea.com
Official Blog: "Dave's Notes" : https://www.empoweredsleepapnea.com/daves-notes

To go to the BookBaby bookstore and view the BOOK, click HERE!

Transcript

Empowered Sleep Apnea: THE PODCAST

Episode 5: THE MOUNTAIN

All content © 2022 Empowered Sleep Apnea, LLC

 For a PDF of this transcript, including CARTOONS (Huzzah!), click HERE! 

00:00 Announcement

Hi. This is Dave. I’m thrilled to announce this news about our Beautiful Blue Book…Empowered Sleep Apnea: A Handbook for Patients and the People Who Care About Them. Firstly, starting NOW, this book is now available in e-book format, for the Apple iBook and Amazon Kindle platforms. No shipping AND the ability to zoom in on the cartoons? How RAD is that? Secondly, from Thankgiving until New Year’s Eve, enter the coupon code HUZZAH—that’s all caps H-U-Z-Z-A-H—and you can take 25 bucks off the retail price for the hardback. That’s a sweet deal, friends, because EMPOWERMENT makes a great gift for someone you love. More info is available at our website, www.EmpoweredSleepApnea.com.  

00:51 Opening Sequence (“Change the Channel!”)
MR. SITCOM: honestly…you should see how this looks on MY OTHER FACE!
KIDS IN THE HALL: change the channel!
MR. ELECTION: …and, America, I don’t even need to get into how much I hate my oppenent’s guts!…
KIDS IN THE HALL: change the channel!
MR. POPMUSIC: …but I know Doomsday’s comin’ soon...
KIDS IN THE HALL: change the channel!

 01:18 Disclaimer
ANNOUNCER: Empowered Sleep Apnea is an educational podcast, which is a bit different from a medical advice show. Medical decision-making can be complex…and even EMPOWERED patients need a partner. So…play it smart, and make sure you discuss your case with your healthcare provider, before making any changes to your medical treatment plan.

…and now…on with the show!

01:42 Episode 5: THE MOUNTAIN

 ANNOUNCER: Empowered Sleep Apnea, Episode 5: THE MOUNTAIN

 As the sun pushes its way through a roiling primitive cloud cover, atop a thousand-tendrilled banyan tree full of greens and yellows and earthy primitive smells, sits a lone crow. 

 At first, he is motionless, a statue, art. 

 And then, he is wind. He is motion. 

 If we travel with him, we can glimpse, over his blue-black wings, a verdant landscape fading into beach, itself fading into deep, dark ocean. 

 For a brief, glorious moment, the clouds part, bathing the island landscape in a miraculous dazzle of brilliant light, a rainbow of impossible color. 

 On the beach: a flash of light. Our flying companion has seen it, too. This is his destination.

 Half-submerged in the sand is a glint of something metallic, attached to an orange object, not quite the size of a bar of soap. A sudden gust of wind blows the sand to reveal text printed on the side—just a glimpse!—and then the advancing tide sends its first wavelet to wash it clean, cover it up.

 A moment, and that’s all. 

 If you’d have blinked, you’d have missed it altogether. 

 Then, with a burst of sand, and a victorious squawk, our companion has snatched it up in his talons, winging away, without even landing. 

 He’s got a lot of experience picking up shiny things, and taking them to where they belong, you know. 

 Taking them to The Mountain.

 From the ground, the crow vanishes nearly immediately, the cloud cover is so dense. If we follow him 

 [which we choose to do, because we can]

 we can see that the metal object that glinted briefly in the sand is a key, and the orange object is one of those floaty rubber spongy keyfobs that keeps your keys from sinking to the bottom of the ocean when they fall off your boat.

 Although the text on the fob is faded, if you look closely, you can still read it: It doesn’t matter how you got here, you can’t swim home!

 As it happens in tropical places, the dense misty fog creeping across the trees disappears with the rising sun, as if on cue from the crow’s wingbeats. A brilliant flash of sunlight glances blue off his feathers, and a crow-shaped shadow is now clearly visible, heading north, inland, away from the crashing rocky beaches of the south shore. 

 Higher. 

 Higher he goes.

 Higher still. 

 Into the thermals. 

 Where he is going, he’ll have a view of the entire Island. He is going to a spot where there’s a lot of Mountain Magic.

 From our avian companion’s point of view, the two dots on the beach could be ants. If we say farewell to our corvid friend and get closer, we can see that they are bipeds. 

 Closer. The clouds are thinner now. The air is clear.

 Still closer, and we can see two humans, slogging through the sand, lurching forward in cartoonish steps, trying to keep their balance. 

 One is walking East, the other West. 

 Each is climbing a steep incline, up…

 Up…

 Up…

 towards a ridgeline running north to south between them, each unaware of the other’s presence. 

 Each has a duffle bag the size of a toaster oven, bouncing on their shoulder.

 The human walking East is a weary-looking white man, stated age 50 years old, though you’d guess he was a decade older. 

 The human walking West is a stocky African-American woman, with a determined set to her jaw that makes her look somehow simultaneously older and younger than her stated 55 years. 

 As we descend, we can see that each of them is carrying a portable dictation tape recorder in their right hand. 

 The 50 year-old man is halfway up the ridge, just as the 55 year-old woman’s head crests the top. 

 Between open-mouthed breaths of air, she is speaking into the tape recorder, though the wind is too noisy from this distance to hear what she is saying. 

 The woman stops walking, and her mouth drops open, here eyes go wide. 

 She has seen the other human. 

 Her left hand flies upward, palm forward, fingers spread, in the universal gesture everyone recognizes as a desperate signal of greeting. 

 She is no longer talking into the tape recorder when she next speaks…

 07:08 Annie’s Story

 [TAPE CLICKS]

 ANNIE: Hello?  Excuse me??? Hello?  

 Do you work here?? 

 Great, too much wind, he can’t hear me…

 …Hey, excuse me? Hello?  

 …Hello??...

 …Ok, he’s looking up, he sees me! 

 Hey, sir, do you work here? 

 I’ve been out here a long time, and there’s nobody…

 …Oh. I see. He’s walking towards me…

 …he’s got a duffle bag just like mine. He’s holding it up.

 ROBERT: (distant) No ma’am…looks like you and I are fellow travelers! 

 ANNIE: …I see…

 [TAPE CLICKS]

 ISLAND MAGIC: Ask her, Robert! Ask about her story! Ask her—

 [TAPE CLICKS]

 ROBERT: …there, I’ve got my recorder rolling. This is Robert again. I’m here with my new friend, Annabelle…Annie…and I’m here…still here on this Island…

 …and something is telling me…I dunno…call it intuition…

 …but I feel like I have to know your story…here you are…duffle bag just like mine…

 So…

 …how did you get here?

 ANNIE: Yeah. Wow. 

 I sometimes wonder that myself... 

 …So: good question! 

 How did I get here?...

 …If I had to trace all this back to a starting point, it’d be the cancer. 

 Yeah. 

 That’s when my sleep started to go wrong. 

 It was the cancer.

 I got cancer pretty young, at 53. Breast cancer. And it was the bad kind, according to the gene test, so I had to have my ovaries out, in addition to the bilateral mastectomy. 

 I mean. 

 One minute I’m a thriving take-charge woman, and the next…they take it all!

 I mean. 

 That’s when I started sleeping poorly. 

 They told me I was depressed, but I don’t even know what that means. 

 I was sad! You know? I was grieving parts of me that were…gone! 

 [TAPE CLICKS] 

ISLAND MAGIC: What about her sleep, Robert? Get her to talk about her sleep!

[TAPE CLICKS]

ROBERT: …keep going, Annie….I want to here more about what this was doing to your sleep... 

ANNIE: I started having a terrible time getting to sleep, and my sleep started to get all…scrambled!..

 ….I’d wake up every two hours with soaking night sweats (thank you, surgical menopause!), and all of a sudden I started snoring, too. 

 I had gained about 20 pounds.

 Somewhere around that timeframe, my OB-GYN recommended that I take venlafaxine, because she said that not only would it help with my hot flashes,

  it would also treat my depression, she said. 

 To be honest, I was so desperate for relief, I was willing to try anything...

…

 …

ROBERT: …Yeah, so what happened then?...

ANNIE: …I can’t recall exactly when my legs started to go crazy, but it was sometime after that. 

 I mean. 

…I’d never felt anything like it! 

…

ROBERT: …What do you mean?...

ANNIE: Well…you know that crazy jumping muscle thing that happens when the doctor hits your knee with the reflex hammer?

ROBERT: …Yeah! 

ANNIE: …or that desperate feeling that you get when you lean back in the chair just a little too far, and you almost fall but DON’T…

ROBERT: …Yeah...I know that! 

ANNIE: Well—imagine that THAT SENSATION is concentrated in your legs—imagine that your whole leg just…wants to do THAT…and imagine that it starts to do it every night, just as you’re trying to go to bed…

ROBERT: Oh my…

Right when you’re trying to go to sleep…

…over and over and over again…

ROBERT: Oh. That sounds…uh…

ANNIE: …awful? 

…Yeah, you got it. 

Crazymaking. 

And the worse I slept, the worse the restless legs symptoms got. 

ROBERT: …wow. That just sounds terrible… 

 ANNIE: I’ll say! 

So I told my OB-GYN about all these symptoms, and, to be honest, she looked a little lost. She said there was something we might be able to do about the snoring, and she sent me for a sleep study.

 ROBERT: Oh, well, that explains why you’re here! So: you have Sleep Apnea?

 ANNIE: Yeah, I guess. 

 ROBERT: What was your AHI?

 ANNIE: You mean…my score? Let me check, I have the report right here…

 (rummages in duffle bag)

 …here it is…my AHI was 33 per hour. They told me that was “severe” sleep apnea…

 ROBERT: Hmmm.  Does it say how the hypopneas were defined?

 ANNIE: Yeah. 

 Oh, now that I’m looking, there are two AHI scores reported. 

 It says the AHI for Rule 1A was 33 per hour. The AHI for Rule 1B was 9 per hour.

 ROBERT: Wow. OK. Well, that AHI of 9 is the one that you should use to talk about RISK. Not the one from Rule 1A. 

 Your AHI of 9 would put you in the MILD SLEEP APNEA group in the major studies that evaluated RISK, so there’s not a lot of signal for increased mortality in the long term, from that degree of Sleep Apnea.

 ANNIE: Wow, Robert! That’s, um…cool that you know that…

 ROBERT: Yah, I know.  I’m a dork, but I had to talk for a really long time about RISK at the Coffee Hut. 

 RISK was a major player for me, in deciding to whether I wanted to get treated. I had to learn my way around the jargon, you know?

 ANNIE: Yeah. For me…I’m not so sure…

 ROBERT: Well, listen…Does your report break down what kind of events you were having…you know…obstructive vs central? You know, they think centrals are less RISKy than obstructives…to…you know?...just live with?...

 ANNIE: Yeah…lemmie see…

 (looks at the report)

 …it says my central apnea index was 3 per hour, and my obstructive AHI was 6 per hour.

 ROBERT: Interesting. So you’ve got some centralish stuff going on on your study, too, huh?

 ANNIE: I guess. You do, too?

 ROBERT: Yeah. Sure did. 

 …

 As a matter of fact…

 …I think I still do.

 [TAPE CLICKS] 

ISLAND MAGIC: The mountain! The mountain! The mountain!

[TAPE CLICKS]

ROBERT: …so…how you doing with that thing?

ANNIE: …oh…you mean…the CPAP? 

Well, originally, I said I wasn’t gonna sleep with a mask. 

 ROBERT: No?

 ANNIE: No way! I, instead, went to my dentist, and I asked him to make me one of those oral appliances. You know, the one that juts your jaw forward?

 ROBERT: Yeah. How’d that go for you?

 ANNIE: Well, I was like THIS with my jaw forward all night long, and I still couldn’t sleep! (laughs)

 I think I slept worse. 

 I mean! Legs goin’ like THIS all night long, and my jaw out like THIS all night long! 

 It was hell! AND it made my jaws jurt!

 ROBERT: So that’s then you went for the CPAP, then ?

ANNIE: I mean—what else was I gonna do? The doctor is telling me I gotta use the mask to breathe, and that nothing’s gonna get better until I use the CPAP…

ROBERT: I get it…so…?

ANNIE: …so…

…now I can’t sleep with a mask on my face…

 [TAPE CLICKS]

ISLAND MAGIC: The mountain! The mountain! 

[TAPE CLICKS]

ANNIE: …so…how about you? How are YOU doing with that thing?

ROBERT: Ok? I guess? 

I mean—some things HAVE improved, OK? 

For example, I used to feel like I couldn’t sleep longer than 5 hours. 

 And, now I’m getting about 6-7 hours of sleep more reliably. Also: I used to wake up really congested in my nose, you know? Coughing and snorting and stuff. And that’s a lot better...

 ANNIE: …but?...

 ROBERT: Well, I’m just not feeling all that much better, you know? I’m still waking up 3-4 times a night to pee. I’m still drowsy during afternoon meetings. 

 And you know, the numbers I’m getting on the machine, my AHI numbers, they’re all over the map!

ANNIE: What’s it supposed to be?

 ROBERT: Well, we want to see it less than 5, but mine tends to run anywhere from 6 to 20, depending on the day.

 ANNIE: Is that a problem?

 ROBERT: well…that’s exactly what I’m hoping I’ll find out…

 [TAPE CLICKS]

 ISLAND MAGIC: The mountain! The mountain! The mountain!

 [TAPE CLICKS]

 ROBERT: Hey, Annie, hold up a sec, where you going?

 ANNIE: Look! 

 No…not there…there! 

 Past that banyan. 

 You see that?

 ROBERT: …yeah?  Yeah!  You mean that weird mountain?

 ANNIE: Yeah. It looks like a hand.

 ROBERT: Yeah. 

 ANNIE: It’s the tallest point on the whole island. I watched a crow make a bee-line straight to it.

 ROBERT: So?

 ANNIE: So…

 So.

 So.

 So, this will sound a little crazy. But here goes. 

 ROBERT: That’s cool, I’ve got your back.

 My dad…was my hero. Ex-marine. National Outdoor Leadership School instructor. He died last November.

 ROBERT: Oh. I’m sorry.

 ANNIE: Yeah. Me too. That’s not the crazy part. The crazy part is that my dad visited me in my dream the other day. And he said this to me: 

 Annie—he says…You know what to do! Go to the Mountain, Annie! 

 Go to the High Point!

 You know what to do.

 He said it three times.

 You know what to do.

 You know what to do.

 [TAPE CLICKS]

 ISLAND MAGIC: Huzzah! Huzzah!

 [TAPE CLICKS]

 ROBERT: Hi, it’s me—Robert--talking again, 

 and my new friend Annie and I are just arriving to the base of a very unusual mountain. 

 It appears that…uh…geothermal energy and seismic shifts and…I dunno…Earth Magic?… have somehow transformed the living rock into an impossible sculpture…

 …the mountain itself is shaped like an enormous upstretched left human hand, with the thumb pointing…more or less…west. 

 It’s truly remarkable.

 Now that we’re here, it’s clear that this is a…destination of sorts…I can see footprints in the sand here…leading over to… there!

 There’s an opening in the rock just at the base of the part of the mountain that I’d call the THUMB, OK? And I can see that the rocky ground there has been worn smooth. 

 Many feet have passed through here, by the look of it.

 Oh, and here, above the opening, there’s a wooden sign. It looks like it’s hand-carved. 

 On it are just five words:

 “Enter Walk and Discover WHY”

 Wow. Well. I guess it’s time.

 ANNIE: I guess so.  You ready?

 ROBERT: I think so…

 ANNIE: OK, then…

 ROBERT and ANNIE (together): Let’s go in.

17:47 CUE MAGESTIC THEME MUSIC SPECIAL: 

 …And You Can’t Swim Home

[sung]

EMPOWERED SLEEP APNEA
EMPOWERED SLEEP APNEA
EMPOWERED SLEEP APNEA
EMPOWERED SLEEP APNEA

You ain’t gonna mess yourself around
You washed up here alone, and now you’re found
Start studyin’ the flowers
It’s time you got your powers
Pick up your feet, let’s take a walk around

Here we go

Where do you go when you need somebody?
Where do you go when you need somebody?
Where do you go when you need somebody?
Where do you go when you need somebody?

 Now it ain’t pretty, when you’re left behind
You waste all of your money, love and time
But soon you will be smilin’
‘Cause now you’re on the island
And here is where you power up your mind

Where do you go when you need somebody?
Where do you go when you need somebody?
Where do you go when you need somebody?
Where do you go when you need somebody?

 EMPOWERED, EMPOWERED,  EMPOWERED,  EMPOWERED, 
EMPOWERED,  EMPOWERED,  EMPOWERED,  EMPOWERED, 

 Psst: It doesn’t matter how you got here…’cause you can’t swim home.

 Empowered.

 Where do you go when you need somebody, and you can’t swim home?

 EMPOWERED

 21:05: Why The Mountain?

 ELLEN: Welcome back to Empowered Sleep Apnea. The Podcast where you learn about Sleep Apnea using the power of stories, from a patient-centered perspective. I’m Dr. Ellen Stothard, and I’m here again in the studio with Dr. David McCarty

 DAVE: Hello! It’s so good to be here.

 ELLEN: …and we are here today for the fifth and final episode of Season One. This episode is about THE MOUNTAIN.

 Clinical decision-making in the world of Sleep Medicine is challenging for a very simple reason. The symptoms a person suffers from—a given individual’s sleep-wake complaints—are likely to come from more than one source.  

 DAVE: Certainly, our new friend Annie has an intuition that her complaints—those things about her sleep-wake experience that are making her suffer—these aren’t all coming from Sleep Apnea. Certainly, supplying her with an airway management strategy didn’t help: neither the oral appliance, nor the CPAP machine helped her in any appreciable way.

 Perhaps this is why the ghost of her resourceful father visited her, encouraging her to use her mind the way an engineer would, to take the problem apart, in a way that allows empowered decisions to be made.

 ELLEN: Here’s the thing: if there’s more than one culprit responsible for your complaints, there’s an interesting new fundamental challenge: 

 How, exactly, does one go about organizing an investigation, when there’s an infinite number of things that can go wrong? 

 I mean…where do you even begin?

 DAVE: The FIVE FINGER APPROACH is a mental mnemonic that begins with a narrative—your sleep-wake complaints—and then guides exploration for possible actionable contributors to those complaints within five different domains. 

 The thing about this strategy: it protects you. 

 It protects your narrative from disappearing beneath the label known as Sleep Apnea, as can happen in this busy world. 

 THE FIVE FINGER APPROACH provides a map for next-level orienteering when you’re trying to figure out what’s wrong.

 Now, the FIVE FINGER mnemonic starts by looking at the palm of your left hand, and you start your count on your thumb.  

 I’ll list them now, and then we’ll take a walking tour of FIVE FINGER MOUNTAIN together

 OK, here we go!

 The THUMB: Circadian Misalignment
INDEX finger: Pharmacologic Factors
MIDDLE Finger: Medical Factors
RING Finger: Psychosocial/Psychiatric Factors
PINKY: Primary Sleep Diagnoses

 ELLEN: Remember how, in our FIVE REASONS TO TREAT discussion, the first REASON, RISK, was the most nuanced, and the most difficult to talk about? 

 DAVE: I remember that!

 ELLEN: Well, The FIVE FINGER APPROACH is set up the same way. The first DOMAIN, that of CIRCADIAN MISALIGNMENT, is kinda hard to talk about, but only because it requires a bit of vocabulary up front.

 DAVE: Look, just like our discussion about RISK required us to understand the difference between obstructive events and central events, and the nuance of how hypopneas are defined, you know--whether we’re using the 4% oxygen desaturation rule, or the 3%/arousal from sleep rule?

 We learned that vocabulary during our stroll around the Bay of Narrative. 

 Well, to talk about CIRCADIAN MISALIGNMENT, we’re going to have to digress just for a moment, and take a look under the hood. 

 You can say that we’re gonna poke around with the machinations of sleep! The HOW of Sleep-Wake signaling. Ya wanna look? Let’s look!

 ELLEN: Let’s do it!

 24:13 The THUMB, Circadian Misalignment, and The Two Process Model of Sleep-Wake Regulation

 [cue mind-bending transportation glissando]

 DAVE: Let’s start by introducing something called The Two Process Model of Sleep Wake Regulation.

 ELLEN: Scientists use the term TWO PROCESS MODEL, just to refer to the idea that there are two different processes going on. Two different machines. We call them Process S and Process C. 

 Don’t worry about the jargon. I promise, this’ll all make sense in a second.

 Let’s talk about Process S first. 

 The “S” stands for “sleep. Or more accurately, the S refers to a concept that we call “sleep pressure”—another term that’s more fun to translate into the following mental game: 

 Imagine your brain is an attic. Imagine that while you’re awake and active and…doing stuff… your brain is working away like one of those old-time assembly line machines and it is letting off all kinds of smoke and fumes. All day long while you’re living and breathing and running around, there are all these fumes that build up in your attic. 

 Now imagine that these fumes make you sleepy. 

 The longer you’re awake, and the more physical stress you are experiencing during that timeframe, the thicker and more intoxicating those fumes will get. Longer and longer you’re awake…more and more fumes build up.

 Now imagine that the only way to get rid of those fumes is to open up all the windows in the attic, to allow a cross-breeze to blow it all away. 

 DAVE: FWOOSH!! 

 ELLEN: (Laughs). Exactly! A beautiful cross-breeze is established, and the fumes ventilate away. 

 Sounds great, but how do we open the windows? The only way to do that is by sleeping.

 That’s it. That’s the only way you can do it.

 You now understand how Process S works! 

 In our brain, those fumes are referred to as Sleep Regulating Substances. If you want to read more about the science behind this fascinating model, check your friendly neighborhood INTERWEBS for articles about The Glymphatic System and sleep pressure.

 DAVE: There’s a problem with Process S as a stand-alone system to explain how and when we sleep, though. It doesn’t stand up to introspection, does it! 

 ELLEN: Whaddya mean, Dave?

 DAVE: We’ve all felt impossibly sleepy during our post-lunch meeting, and then experienced the inexplicable “second wind” that allows us to rally for Taco Tuesday and half-price margaritas! 

 I mean! What gives? If it’s all about steadily advancing sleep pressure (ie: “fumes in the attic”), how can we explain these fluctuating degrees of sleepiness during the day?

 ELLEN: Well, it turns out that the answer lies in our other friend, Process C. 

 And here, the “C” stands for “circadian.”  (We’re very creative in the sleep world, as you may have noticed)…

 Circadian means “approximately a day” or “around a day” and it refers to the idea that our biological rhythm intrinsically cycles at a rate of about 1 full revolution per day, very similar to the 24-hour cycle of our planet. 

 But there is variation between person to person and very few people have exactly 24-hour timing, so your circadian system’s primary job is to take the information about the external time and translate it into your body. 

 DAVE: External time, meaning THE SUN.

 ELLEN:  Yes, exactly. So how does your body know what’s going on inside, and what time it is outside…it does this to keep time, or to regulate all kinds of processes inside the body…to make sure that they happen at the right time!

 One of the biological rhythms that cycles most noticeably is our level of alertness. 

 It’s funny to think about this, but our ability to be awake is governed by a network of structures in the deep brain. 

 Nothing that can see the light from the outside world…

 This network of structures is collectively called the Ascending Reticular Activating System. A-R-A-S, and we can call it the ARAS for short.

 The ARAS fires, and you wake up. If you were to perform an evil experiment, and selectively burn up all the of the cells of the ARAS, you’d make a person who never wakes up again. 

 It helps to think of the ARAS like it had a volume knob or a gas pedal. The higher the volume or the more gas you give the system, the more awake you’ll feel. 

 DAVE: One of the things your brain does, is it helps you stay awake toward the end of the day, even though your attic is full of those fumes. In fact, in the last two hours before your usual bedtime, the ARAS is at the highest point of activity it will reach all day.

 Circadian rhythm researchers have a name for this timeframe. 

 They call it THE FORBIDDEN ZONE!

 ELLEN: We love that name, because it sounds like a cool 1950’s science fiction movie, but it’s also very informative. 

 It’s called THE FORBIDDEN ZONE, because it’s really hard to fall asleep during this part of the circadian system. The ARAS is really powerful, and it’s really good at keeping you awake.

 DAVE: Most of us humans have a timeframe in our circadian cycle that is built for prolonged sleep. It happens right after our FORBIDDEN ZONE, as a matter of fact! Sleep Medicine clinicians refer to this as the Circadian Sleep Phase, because it’s the time that circadian system is promoting sleep as opposed to being awake. 

 29:38 The Circadian Rhythmo-Wheel

 One of the teaching points of Empowerment is that it’s always easier if you can just see something for yourself! The teaching points about THE FORBIDDEN ZONE and THE CIRCADIAN SLEEP PHASE are really visual. That’s why I made a really cool GIZMO called the Circadian Rhythmo Wheel! 

 CHORUS: Rhythmo-Wheel don’t talk back! Rhythmo-Wheel don’t talk smack!

 DAVE: You can access a PDF of this on our website. Print it out for yourself on cardstock, and put it together yourself. 

 I’ll wait, If you want to do that now…

 [CUE RAD MAKER MUSIC]

 DAVE: OK. Now you got your Rhythmo-Wheel. 

 Turn the blue cloud to the clock time where you’re usually sleeping for your prolonged sleeping interval.

 You’ll see it’s a twenty-four hour clock. Midnight’s at the top, and Noon’s at the bottom. Now, if you need to guesstimate, you can download a two-week sleep diary and see if this gives you a better estimation.

 We’ve got a link to the AASM two week sleep diary in the show notes.

 Once you can see where your circadian sleep phase is, now turn your attention to the FORBIDDEN ZONE. Here, we have a new teaching point. You see that badge, right there in the middle of the FORBIDDEN ZONE. The one that says DLMO?

 Yeah, that one.

 That’s your DIM LIGHT MELATONIN ONSET. 

 That’s an important event. You know why? That’s captain DLMO. That’s the captain’s voice coming on over the loudspeaker, saying…

 CAPTAIN DLMO: “Put your traytables up. Put your seatbacks to their full upright positions. We are making our final approach into SleepyTown Airport.”

 ELLEN: Here’s the thing about Captain DLMO, though: He’s shy! 

 DAVE: Awwww!

 ELLEN: He doesn’t come out in the bright light! He only shows up for his shift when the lights go down. The only thing that doesn’t scare him off is very dim light, like the nice orange glow of a campfire. 

 DAVE: For most of us, the wonders of electricity and technology have made Captain DLMO a terrible employee, showing up only after we’ve gone to bed, and after we’ve turned the lights out. In other words, for most of us, we’re trying to land the plane with the wheels up and the beverage service still in the aisles. 

 ELLEN: The thing about the timing of the circadian sleep phase: it’s not written in stone. You can change the timing of the whole production very easily. 

 Like when you travel…

 DAVE: …across time zones…

 ELLEN: …or experience the dreaded transition to daylight saving time. 

 There are a few ways this happens but much of it has to do with what we do towards either end  of the day.

 DAVE: Take a look again at the Rhythmo-Wheel. Take a look at the little light bulbs that are situated up near the forbidden zone, and during the first part of the circadian sleep phase. 

 You see how they have Red Arrows, in the clockwise direction? 

 That means that LIGHT going in your eyes during that timeframe will try to push your circadian sleep phase LATER the next day.

 This happens by inhibiting or delaying the production of melatonin, putting a pause on the internal clock, starting a melatonin phase later which then makes the circadian sleep period stretch later into the next day.

 ELLEN: Look at the same light bulbs, but on the second half of the circadian sleep phase—see how they have GREEN arrows pointing counter-clockwise? 

 That means that LIGHT in your eyes during that timeframe will try to move your circadian rhythm back the other way, or advance the timing of your circadian clock.

 This is one of the important things that we emphasize as circadian biologists. 

 Remember how I mentioned before that not everyone’s circadian cycle is exactly equal to 24 hours? If that’s the case, then every single day your body needs to adjust so that it doesn’t keep adding up. 

 For most people this in in the form of “overage charges.” That’s why morning light is so important, to get that advance and end melatonin production and get the day started right.

 [cue applause!]

  ELLEN: Without this morning bright light, many people’s circadian timing will be delayed and the later evening light will make it even worse. 

 DAVE: And it’s not just light towards the end of the day that will delay you. Light’s just the most important zeitgeiber, a cool German word that means Time-Giver. A number of non-photic elements, such as eating, exercising, socializing, and just plain excitement—all of these tend to be phase-delaying elements at bedtime, as well.

 ELLEN: And here’s a frustrating fact about our circadian rhythms: It’s much easier to delay than it is to advance. 

 DAVE: Huh…Kind of like government work! (laughs)

 ELLEN: …easier to delay than it is to advance…I get it! Dad Joke!

 Point here is this: Many people can get stuck, seemingly trapped, with a delayed circadian sleep phase. 

 Maybe this happened because you practiced too many of those phase-delaying behaviors after dark. Maybe it’s because you had the lights on, and CAPTAIN DLMO was late for his shift. When this happens, you can find yourself with the challenge of trying to fall asleep on top of your FORBIDDEN ZONE!

 DAVE: Folks in this predicament will tell you they’ve got insomnia. 

 Worse still, they’ll usually say that they have insomnia, and that sleeping pills don’t do anything! Their usual experience is that it’ll work for one night, and then the next time, they’ll make the claim that they must have gotten used to it. 

 What’s the problem? 

 The problem is that they’re trying to go to sleep on top of their FORBIDDEN ZONE. It might work once, the first night, when you were really sleep deprived and you’ve got a lot of sleep pressure on board. 

 But after that, when you’ve caught up on your sleep, the sleeping pill is just not strong enough to overcome the FORBIDDEN ZONE.

 ELLEN: In our modern, civilized world, lots of us will have this problem. And because our circadian rhythm is such a powerful force, it’s the first place to explore. 

 Circadian Misalignment is THE THUMB of the Five Finger Approach.

 35:19 Proactive Wind-Down Time

 DAVE: If you think you’ve got a delayed circadian sleep phase, or if you just want to protect your circadian sleep phase from getting delayed, a simple measure that you can do is called PROACTIVE WIND-DOWN TIME. 

 It works like this: choose a place in your home that’s quiet and peaceful. The only caviat: it can’t be in your bed! The ideal place is a spot you can kick your feet up and lean back a bit, with low light. You can use a reading lamp, but try to avoid backlit reading materials. Do something relaxing (coloring, journaling, reading poetry), listen to soothing music. Have some chamomile tea. Have fun with it. The point is to do it every night, for the sixty minutes before bed. 

 OFFSTAGE DAVE: If you can’t do 60 minutes, start with 5 minutes. Even a little wind-down helps! 

 DAVE: Doing this is gonna protect CAPTAIN DLMO, and help you get your transition to sleep.

 36:13 The INDEX FINGER: Pharmacologic Influences 

 ELLEN: Once we’ve thought about whether the timing of the circadian cycle might be part of the problem, we can then move on to the index finger. 

 DAVE: The index finger represents PHARMACOLOGY, and by this I mean: any substance you can eat, ingest, consume, smoke, drink, inject, or inhale.   

 The index finger is not just your medication list, it’s recreational and social drugs, too. 

 ELLEN: The truth is: lots of drugs that you take for other reasons might have an effect on sleep. For example, beta blockers—a commonly prescribed drug class for heart disease and high blood pressure—can cause insomnia and nightmares in some patients!

 DAVE: Still other drugs can contribute to symptoms of daytime neurobehavioral impairment, causing symptoms like drowsiness, brain-fog, and inattentiveness. Sometimes, you can change the timing of the medication. Sometimes, a different medication can offer the same benefit without causing problems. 

 I want to emphasize here: do NOT change your medications around on your own. Always always always: speak to your provider, and make sure you have a plan going forward. Nerd safety message over. That is all.

 ELLEN: There is a PDF of medications that can affect sleep and wake is available in our show notes. This is taken directly from the book.

 37:23 The MIDDLE finger: Medical Influences

 DAVE: The middle finger represents the influence of underlying medical illness. Let’s say you were trying to help someone with Sleep Apnea…

 ELLEN: …Ok…

 DAVE: …but that person happened to be strapped to a bed of nails. 

 ELLEN: I get it.

 DAVE: Right? There’s no CPAP setting that’s going to fix the fact that he’s sleeping on a bed of nails.

 ELLEN: In this example, the bed of nails could be any medical problem that causes discomfort, right?

 DAVE: You got it. So the probing that happens here is: could we control these sources of discomfort any better. And if we can’t, might it be reasonable to offer the patient some relief, to allow some rest, despite the fact these discomforts are present.

 ELLEN: You mean: sleeping pills?

 DAVE: Yes, Gasp! I mean sleeping pills. 

 Although, I admit, Sleeping Pills are a problematic drug class, I will point out: so are many drugs we prescribe without a second thought. Statins have their problems. Antiarrhythmics have their problems. Anticonvulsants have their problems. All of these agents can, themselves CAUSE medical disease. 

 The discussion about sleeping pills is a task for another day. And we will get there. Suffice to say that Empowered patients don’t make decisions out of fear. Empowered patients make decisions based on knowledge.

 We will get there. I promise. 

 We will get there.

 38:42 The RING finger: Psychosocial and Psychiatric Influences

 ELLEN: The ring finger is a broad domain: Psychosocial and Psychiatric influences. 

 It’s a reminder that all sleep-wake complaints will filter through a lens of mental well-being and personal safety. Trauma, loss, grief, depression, anxiety, and domestic abuse may contribute prominently to the sleep-wake complaints that bother you most. Consider reaching out to your primary care provider or qualified mental health professional for guidance, if you believe there’s growth potential there.

 39:28 The PINKY: Primary Sleep Diagnoses

 DAVE: The pinky finger is where the tour of the mountain stops. The pinky finger is where we can stop to consider the diagnoses that are usually awarded at a Sleep Medicine clinic. Things like Sleep Apnea, Restless Legs Syndrome, and Narcolepsy. If you have Sleep Apnea, here is not just where you ask yourself: have I resolved this issue? It’s also where you ask yourself: is there something else?

 39:51 Robert and Annie: The MOUNTAIN Report

 So, what about our friends, Robert and Annie? What did they learn from their journey to THE MOUNTAIN?

 ELLEN: Annie learned a lot on her visit to the mountain. 

 First of all, her two-week sleep diary gave her insight into circadian misalignment. 

 She determined that her sleep phase was delayed, and she decided to implement a Proactive Wind-Down routine.

 DAVE: Empowered thing to do! 

 In the INDEX finger, Annie learned that the venlafaxine she was taking for her Hot Flashes and Depression, this was creating more problems than it was solving. 

 Not only was the drug contributing to her insomnia, it was making her Restless Legs symptoms much worse. 

 And, because the restless legs symptoms was creating problems with leg movements during sleep, it was contributing to her central apnea physiology, simply by virtue of being disruptive to her sleep.

 You remember back in Episode 2, when we talked about the Many Moving Parts of Sleep Apnea? 

 Now we know why that’s important!

 ELLEN: Totally makes sense!

 Well, the good thing is: Annie eventually tapered and stopped the venlafaxine—this improved her restless legs and insomnia symptoms somewhat. Her Sleep doc gave her a trial on low-dose zolpidem as a management strategy for her restless legs.

 DAVE: Zolpidem! That’s a sleeping pill! Right? We just got through talking about…

 s-s-Sleeping Pill!

 So it’s a little strange to think of it like this, but Restless Legs symptoms get worse when you’re sleep deprived. 

 In other words, the more your legs keep you up, the worse the physical sensations of restlessness can become. As a result, a simple strategy for management can be hypnotic pharmacotherapy. Sleeping pills, in other words. This just happens to be the strategy that would work best for Annie.

 As I said earlier, there is a whole lot more that needs to be said about sleeping pills…this is coming. Just not today.

 For now, we are walking. We are walking. We are learning the process.  

 ELLEN: As Annie explored the Ring finger, she was able to square off with quite a bit of grief, related to her sense of physical violation, following her cancer diagnosis, and her surgeries. The EMPOWERED decision she made whilst she was here: She decided that she would reengage with her therapist.

 DAVE: For the pinky finger (this is where her Sleep Apnea would fit in), Annie conceded that she wanted to investigate her options further. 

 She had a suspicion that her Sleep Apnea was worsened under the burden of her Restless Legs, because of the contribution of the central component, and that things might be different once she had discontinued venlafaxine, particularly if she lost some weight, and started doing some work to try to become a better nose-breather. 

 The EMPOWERED decision she made here was that she would re-visit her Sleep Apnea with another home sleep apnea test, after she has made progress on her weight loss and nasal breathing goals, and after she was off the venlafaxine.

 42:47 Treatment Emergent Central Sleep Apnea (TECSA)

 ELLEN: Well, that’s great to hear about Annie. So…how about our friend Robert?

 DAVE: Let’s cut to the chase: Robert visited the entire mountain. He decided to speak with his providers about some of his meds, which might contribute to insomnia. But the biggest signal he got was still coming from his Sleep Apnea. 

 ELLEN: The numbers he is getting from his machine show an AHI that’s running typically in the teens.

 DAVE: …all signal is pointing to treatment emergent central sleep apnea as the culprit…

 ELLEN: Treatment emergent central sleep apnea. 

 CHORUS: T-E-C-S-A—we could just call it TECSA! HUZZAH!

 ELLEN: OK.  So, another term for this is COMPLEX SLEEP APNEA. Don’t get thrown off by the jargon. The reason that this happens is because of something we’ve already talked about.

 DAVE: You remember in Episode 2…we learned central apnea physiology has a few moving parts. For some folks, using positive airway pressure therapy can create an instability to the breathing pattern during sleep. A pattern where breathing waxes and wanes. A pattern where the effort to breathe sometimes stops for a spell. 

 This pattern happens to be called central sleep apnea.

 43:50 Dr. Tom Minor helps teach TECSA!

 ELLEN: To learn more about treatment emergent central sleep apnea, we decided to call pulmonologist and sleep specialist Dr. Tom Minor. 

 DAVE: Dr. Minor has been practicing Sleep Medicine here in Boulder Colorado for over 25 years! He reads sleep studies and cares for patients in Rocky Mountain High, folks…some as high as 10,000 feet above sea level!

 We figured it’d be hard to find anyone on the planet with more experience dealing with TECSA—that’s treatment emergent central sleep apnea. 

 [CUE RAD MAGIC PAYPHONE SOUND EFFECTS]

 So, we’re going to the Empowered Sleep Apnea PAYPHONE, lemmie just get her wound up here…OK…what?...forty-…OK…what? 

 Oh, no.

 [clicks intercom]: Ellen, it’s doing that humming thing again! [intercom clicks off]

 OK. Forty-  two cents and your iTunes password?...that’s a new one…let me just…uh…get that…keyed in…here it is…it’s dialing…

 …it’s ringing now…oh? Oh!

 [clicks intercom]: Ellen, the hum stops when you dial! [intercom clicks off]

 …ringing…and…ahhh! We got ‘em! Hello! Dr. Tom Minor! Welcome to the program. Welcome to Empowered Sleep Apnea!

 TOM: Well, thank you so much for the invite. I’m excited to be here. 

 DAVE: Dr. Minor, your primary practice is at an altitude of 5400 feet above sea level. What percentage of your patients would you say has to contend with treatment emergent central sleep apnea?

 TOM: You know, I would say of the patients we put on PAP therapy, I would say it’s probably around 20%...

 …which is definitely higher than you’ll see in the general literature…

 …but because of the altitude, we see more Treatment Emergent Central Sleep Apnea…

 …realistically, some of that may actually be occult central sleep apnea…I know you’ve talked about this previously…and especially at altitude, what might look like obstructives may already be kind of a hidden or occult component of centrals…especially if you don’t break down the hypopneas, which a lot of labs don’t…

 …and even if they DO break down the hypopneas, the accuracy in breaking down hypopneas is not as great as we’d like it to be…

 DAVE: Wow! Either Dr. Minor listened to Episode 2, or he really knows what he’s doing!

 OFFSTAGE DAVE: I’d say that’s the 25 plus years of experience talking!

 TOM: …so…I would say for the patients we put on PAP therapy, I’m gonna say around 20% were having central sleep apnea.

 DAVE: …and, of course, our EMPOWERED patients know that there’s no One Size Fits All answer for this, and that there are PLENTY of moving parts, when it comes to Sleep Apnea—Central Sleep Apnea, included!

 TOM: Exactly…Age, sex (males are more likely to have this), and certainly the altitude plays a role, the higher you go, the more it becomes…prevalent and even almost universal, once you get really high…I read sleep studies up in Leadville…and…it’s not universal there, but it’s almost more often than not, I think…that we see…at least some centrals…  

 ELLEN: So, if someone suspects they might have treatment emergent central sleep apnea, what are their options?

 DAVE: …and as we go through this, I think it’ll be pretty clear why it’s good to have a good coach on YOUR side…there’s maybe more options than you think!

 …Dr. Minor…what do you think?

 TOM: A couple of main options…one of them is Adaptive Servo-Ventilation…ASV.

 DAVE: ASV is a positive airway pressure device with a PhD! It has special internal algorithms that help it not only treat the obstructive component, but also to read the breathing pattern…to stabilize the central apnea physiology…and not create those pauses in breathing.

 TOM: …it’s probably the most likely thing to work, and to treat both the obstructive and the central sleep apnea.

 …the other option is…putting you on CPAP.

 [Cue Record scratch sound effect, followed by crickets…]
 
 DAVE: Whaaaa? If CPAP causes the person to have central sleep apnea, why on Earth would you start ‘em on this therapy?

 TOM: …although that might seem counterintuitive, because you say: “Gee, well, my sleep study showed that I have treatment emergent central sleep apnea…why would you treat me with something that’s going to give me treatment emergent central sleep apnea?”

 DAVE: It turns out: there’s a good reason! 

 TOM: …studies show that the majority of patients who have Treatment Emergent Central Sleep Apnea on a sleep study…it will abate over the period of a couple months…the majority have gotten better…I’ll say 50 to 85% or so…have gotten substantially better…

 DAVE: That’s true for Flatlanders…but what about up here in the Mountains?

 TOM: …one caviat to that is that those studies were done at Sea Level…and I don’t think I see quite as many people in which Treatment Emergent Central Sleep Apnea resolves…but still…some patients do…

 DAVE: …so, the ASV sounds pretty cool, but how much does it cost?

 TOM: ASV is the most likely to work, but it’s also gonna be the more expensive route.

 You have to go back to the sleep lab…depending on your insurance, that could be zero dollars if you’ve got good insurance—if you’ve got Medicare and a good supplement—but if you are in a high-deductible insurance, that could be a couple thousand dollars…

 [cue cash register sound effects]

 …and then the ASV device itself—although it looks exactly like a CPAP machine, it costs about 3 to 4 times as much…if you’re in a high-deductible plan, it could cost you 3 or 4 thousand dollars…

 [cue crowd booing sound effects]

 DAVE: …all the more reason why it helps to plan ahead, and to have somebody on your side, helping with the coaching. 

 Well, what if you DON’T have an ASV machine? Are there things that you can do to your own CPAP unit to make it more effective against treatment emergent central sleep apnea?

 Turns out, there are!

 One of the simplest things to try, according to Dr. Minor, is just running supplemental oxygen through your existing CPAP machine. Oxygen concentrators are a new way of delivering therapeutic oxygen, that don’t require dangerous compressed gases. 

 An oxygen concentrator is an electric appliance that plugs into a standard household outlet. It’s about the size of a kitchen trashcan. 

 A little oxygen run through a standard CPAP machine can often magically stabilize central apnea physiology, especially up here at altitude.

 The big problem? It’s hard to get oxygen therapy covered under most insurance plans. That doesn’t mean EMPOWERED patients shouldn’t know about it. There are often second hand concentrators for sale on places like Craig’s List. You can get a new one for usually less than a thousand bucks.

 So, what about things besides oxygen? 

 TOM: …there’s a whole menu of things I can do to try to improve the treatment emergent central sleep apnea with a patient who’s already on CPAP or in which we’re gonna put ‘em on CPAP and see how they do…

 …often patients are put on CPAP at kind of the generic settings… 4 cm of water to 20 cm of water pressure range that an Auto-Titrating CPAP machine can use…that’s the generic settings…

 …if you just got put on a unit, or you went and bought one online and are kind of doing this yourself…you’re probably on that 4-20 range…and that is more likely to contribute to treatment emergent central sleep apnea, than if you were to lower the pressure and narrow the pressure range…

 DAVE: …we LOVE this idea! Making the device gentler, so it’s less likely to overventilate you, and contribute to that central apnea physiology!

 TOM: …so if I see somebody who has a wide pressure range—that full 4-20 or less—I’ll say: “Let’s change the setting…we may get some traction out of that.”

 I may just choose a fixed pressure of 5, 6, 7, 8, something like that, kind of depending on how bad the obstructive was, what their body habitus, their sex, age, things like that…

 …but I’m usually choosing a low fixed-pressure and: “Let’s bring you back in two weeks.”

 DAVE: Brilliant! Making the device friendlier, and having a clearly-stated follow up plan! THAT’s patient-centered medicine at its BEST! 

 What about some other inexpensive options? What about changing the position of your sleep?

 TOM: …the other thing is I’ll question them: “What position are you sleeping in?”

 …because treatment emergent central sleep apnea is classically worse when you’re on your back…so if you’re sleeping on your back, is it a reasonable option? Can we get you to sleep on your side?  

 DAVE: Super-cool! But what about that setting on the device that’s for comfort that’s called Expiratory Pressure Relief?

 TOM: …you can turn off the expiratory pressure relief…that’s the patient comfort setting that drops the pressure a little bit right as you start your exhalation…

 …generally it’s pretty benign and I tell people: “Just choose what you want” but in this case I’d say, let’s turn that off…

 DAVE: Turns out that another signal that contributes to that tendency to over-ventilate with a CPAP machine is when the mask is leaking…or if air is leaking out your mouth!

 TOM: …we can be also addressing LEAK as well…if you’ve got a lot of leak, it can be flushing the CO2 out, that—normally when we exhale we have a little CO2 that kind of is in our nose, and around our face…

 …well if you’ve got a lot of leak, that’s all being flushed out, and flushing out the CO2 actually tends to drop your CO2 level in your blood more quickly than your brain is used to…

 … and so THAT promotes this instability…your brain is constantly playing catch-up with the CO2, it’s trying to…it’s overbreathing to try to get the CO2 down, and then it…the CO2  level is too down, and so it tells you to stop breathing completely .

 DAVE: …the type of mask you have seems to make a difference as well. Now, normally, you’ll hear me singing the praises of nasal masks, because they promote nasal breathing…which is just healthier than mouth-breathing…in a case like treatment emergent central sleep apnea, it can make sense to use a bigger mask…

 …because…there’s more what we call Dead Space under the mask…which just means there’s more opportunity to re-breathe CO2.

 TOM: …if you were to address that leak, then that may help a little bit, and also…using a larger mask, which kind of helps you re-breathe a little bit…

 DAVE: Well, what about the person with numbers all over the map like Robert’s, but they don’t feel bad! If they don’t have any other medical problems, and they really don’t feel bad with it…do they need to worry about those NUMBERS?

 TOM: …if you FEEL pretty good, I may just say…you know…like they said in the Viet Nam war, just..um…maybe we should just declare victory and get out…

 …you know, if you’re feeling pretty well…maybe that’s…you know…”GOOD” is good enough.

 DAVE: Even though central apnea physiology hasn’t classically been linked to increased risk for cardiovascular disease and stroke the way Obstructive Sleep Apnea has been, the intermittent hypoxia with Central Sleep Apnea might be considered a threat, if you have vulnerable comorbid conditions, such as a history of cerebrovascular disease, or heart disease. As a result, he added on this caviat:

 TOM: …usually you want to insure they’re having significant hypoxemia or oscillations…significant desaturations…so I would usually perform an overnight oximetry…

 …you know what “significant desaturations” ARE vary, from person to person…but…

 …that’s one thing I would probably do before I would say: “Sure, let’s just not work this through anymore, let’s just be happy with what we have…”

 …if you’re asymptomatic and NOT having significant desaturations…we can probably be pretty happy.

 54:02 Cartoon Showcase

 [CUE RAD CARTOON VORTEX SOUND EFFECT]

 DAVE:. …and that sound is my reminder to showcase the cartoons that helped to spark today’s exciting program. 

 The first one I am really excited to present to the world because it’s so darned USEFUL is the Circadian Rhythmo-Wheel. 

 In the show notes there is a link to download a PDF of this. It’s a rather large document, so give it time to download. It’s a beautiful 600 dots per inch full color and full-size document that you can print out at home. 

 I’d recommend that you do it onto card stock, if you have it, but you could do it on regular paper. 

 Then, simply cut out the wheel, and mount it to the decoder base with a paper fastener, and you’ve got yourself a really RAD biologic decoder-ring GIZMO.

 ELLEN: Biologic decoder-ring!

 DAVE: Yeah!

 ELLEN: SO, the second cartoon is called Fumes in the Attic. You’ll see how it’s just a fun way of understanding the scientific concept that we introduced in this program called Process S, the concept of homeostatic sleep pressure.

As always, links to the cartoons themselves are included in the show notes. 

 55:10 Remembering the Adventure

 DAVE: Well, that about does it for another exciting episode of Empowered Sleep Apnea: THE PODCAST. This was a special episode, because in this episode, we finally got a glimpse of Sleep Medicine from higher ground, from the vantage point of THE MOUNTAIN. 

 We got an understanding that Sleep Apnea is always something that must be considered within the context of an individual’s personal narrative—which is to say: their own Sleep Wake Complaints—but also within the landscape of the many other forces which may be present, which may also be contributing to those complaints.

 We learned how to talk about our own circadian rhythm, and we’re now equipped with a really neato Gizmo that helps us understand it!  We’ve learned about our FORBIDDEN ZONE, and how this might contribute to sleep-onset insomnia. We’ve learned about our DLMO—dim light melatonin onset—DLMO! Captain DLMO!—and we’ve learned to treat him with respect and keep the lights low for him, so that he shows up ontime for his shift, and helps us make that transition from wake to sleep.

 And finally, a special shout out to Dr. Tom Minor for helping to teach some really important points about one of many complications/competing diagnoses, treatment emergent central sleep apnea.

 It’s nice up here, from the crow’s eye view. Being able to see the whole landscape allows us to feel informed about the journey. 

 It gives us agency; it allows us to be part of the decision.

 Who knows where your EMPOWERMENT will take you next?

 Who knows, indeed!

 Maybe it’ll be Colorado.

 ELLEN: Boulder, Colorado!

 56:48 Cue Majestic Theme Music and Closing Credits

 ANNOUNCER (c'mon...y'all know it's still DAVE!): Empowered Sleep Apnea is a production of Empowered Sleep Apnea, LLC. 

 The show was written and performed by David E McCarty, MD, FAASM and Ellen Stothard, PhD. 

 Special guests this episode: LeVette Fuller playing the role of Annie, and Dr. Tom Minor as himself! 

 All sounds on this program were either made by the performers, or were cobbled together from public domain sounds we found lying around the house.

 Theme song and special choral arrangements by 25% Fred.

 Cartoons this week were discovered at the bottom of the ocean, locked in an oak box festooned with barnacles, menacingly protected by a giant squid.

 Dr. McCarty’s singing range is positively influenced this week by fearless joy. Dr. Stothard’s Dim Light Melatonin Onset enhanced this week by a weekend of camping.

 Tune in this January, when Empowered Sleep Apnea: THE PODCAST returns for Season 2. You know you have questions.

 The adventure…continues…

 It always does, doesn’t it?

 Coming up next…your Sleep Medicine Dad Joke

 58:16 Sleep Medicine Dad Joke

 DAD:  OK OK OK..I gotta tell ya…it’s pretty incredible…I haven’t slept in SEVEN DAYS!

 NOT-DAD: Seven Days? Holy smokes, Daddy-O! That’s a long time! I can’t believe you’re even standing up! How do you do that? Not sleep for seven days?

 DAD: It’s OK! It’s OK! I slept at night! Ya get it? Didn’t sleep for seven days? Because I slept at night! Hahhh? Right?

 NOT-DAD: Oh! Yeah! I get it. You slept at night! That’s hilarious!

 58:49 END PROGRAM