The Sleep Apnea Crisis Medicine Is Still Missing | Dr. Bertrand R. Desilva

Sleep apnea is often treated as nothing more than snoring, but what if it's one of the biggest hidden drivers of chronic disease?
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00:02:08 – Sleep Apnea Drives Chronic Disease
00:04:40 –Why Specialists Keep Missing It
00:09:09 – Outdated Sleep Apnea Diagnosis
00:15:01 –Why Early Intervention Matters
00:20:48 –Is CPAP Really the Long-Term Answer?
00:37:21 –The Patient Stories That Changed Everything

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In this eye-opening conversation, Dr. Bertrand R. Desilva, a pulmonologist, critical care physician, and sleep medicine expert, explains why obstructive sleep apnea remains dramatically underdiagnosed despite its profound impact on cardiovascular disease, hypertension, atrial fibrillation, diabetes, cognitive decline, ADHD-like symptoms, and overall health.

Together, we explore why the current diagnostic criteria are decades old, how today's healthcare system often overlooks early warning signs, and why many women, children, and younger adults fall through the cracks. Dr. Bertrand R. Desilva also shares unforgettable patient stories that demonstrate how identifying and treating sleep-disordered breathing transformed lives, from reversing years of academic struggles to preventing serious long-term health complications.

The discussion also challenges conventional thinking around CPAP, early intervention, airway development, orthodontics, pregnancy, childhood breathing disorders, and the future of sleep medicine. If you've ever wondered whether poor sleep could be the missing piece behind chronic health problems, this episode offers a perspective that may completely change the way you think about breathing, diagnosis, and prevention.

#cpap #sleepapnea #breathinghealth

To learn more about Dr. Mark A. Cruz, DDS. visit:
https://www.MarkACruzdds.com
Dr. Mark A. Cruz, DDS. 
32241 Crown Valley Pkwy #200  
Dana Point, CA 92629  
949-661-1006 

Transcript

The Obvious Clue Getting Missed

SPEAKER_00 0:00

People are not looking at the obvious. I don't want to blame the cardiologist and say they're not looking at the obvious. It's something that they are not familiar with. They feel that it's really the purview of the primary care doctor to look at the patient more holistically and refer for a sleep study. For example, a GI doctor notices when he's doing endoscopy that the patient is sedated, he has anesthesia with him to look after the airway. And he notices that the patient's oxygen saturation went down. They had to bag him and he would come and they tell the patient, oh, by the way, we think you're supposed to be a sleep acne. Why don't you go back to your primary and get a referral? They will not take it upon themselves to make

Why Breathing Connects Everything

SPEAKER_00 0:42

it.

SPEAKER_01 0:42

What if breathing is the missing way? Welcome to breathe, sleep, and smile. Breathing, sleep, patient growth, and health connect. This is the airway conversation beyond buzzwords and connecting the dots that are often missing. My good friend Bertrand. Known you for a while. How things going?

SPEAKER_00 1:09

All right, well, thank you. Thank you for having me here today. I appreciate your invitation and uh the ability to participate in a good conversation today.

SPEAKER_01 1:17

Absolutely. I first time that uh I I heard you you spoke at one of our um our mini residency. This is years ago. I had to have been like 12 years ago or so. Uh and um you gave such a fantastic perspective on

The Dick Cheney Wake Up Call

SPEAKER_01 1:35

the whole topic of obstructive sleep acne. I think it was titled something of um obstructive sleep acne, uh a cry for hope. And and what I really loved was that story of how you explained what had happened to Dick Cheney. Um, being in this system, I don't know if you remember, but being in the system where he kept on being treated for cardiovascular problems. No one's really looking at uh sleep medicine. So I think you know, it went from, you know, pulmonary hypertension to, you know, whatever, arrhythmia eventually turned into uh aphib, and then he was on a pacemaker, and and there's this whole thing. I remember you talking about how the medications just kept on escalating, never really taking care of it. Um do you remember that?

SPEAKER_00 2:30

I do. Yeah.

SPEAKER_01 2:32

Could you could you maybe give a quick synopsis of it? Because it it does give us a microcosm of the problem.

SPEAKER_00 2:38

Right. So um basically sleep apnea is the central orchestrator of a lot of the pathologies that we see both in the office as well as in the intensive care unit. And if it's not well recognized or even investigated as an outpatient, uh it progresses and progresses uh to the point where the sleep apnea will cause pulmonary hypertension, uh, it'll cause uh left ventricular diastolic dysfunction, it'll cause enlargement of the atria, and then subsequently they end up uh with atrial fibrillation. And the atrial fibrillation is very difficult to control because the sleep apnea is not being addressed. And even after uh many medications, they find that the atrial fibrillation is uncontrollable, high rate, and uh frequent episodes of paroxysmal atrial fibrillation with the risk of stroke. So the patients often end up on anticoagulation, arrhythmic uh medications which have side effects. And these side effects include bradycardia, they end up with a six sinus syndrome, they may end up getting a pacemaker, they may end up getting uh repetitive ablations uh before the sleep apnea is actually addressed. And uh very recently I had a patient referred over for evaluation of sleep apnea after having had several ablations, and those ablations uh were causing heart block, and he was on the verge of getting a pacemaker put in. Um but no addressing the sleep apnea. And when we studied him, he was very, very severe and uh relatively easy to treat uh in terms of getting his sleep apnea brought under control. And then he had a significant reduction in his heart rate in the incidence of atrial fibrillation.

SPEAKER_01 4:34

It's it's crazy, and and just for for our audience, uh just to clarify, you're a critical care uh physician, um, you're in the ICU, you're a pulmonologist by by training, and um, I know your medical director, been medical director of of different um different hospitals. So you live in the ICU and you've you've lived through these these problems.

Siloed Care And Lost Referrals

SPEAKER_01 4:58

And um would you comment on why you think this happens, that the cardiologist isn't really looking at it, or people are not looking at the obvious?

SPEAKER_00 5:11

Well, I don't want to blame the cardiologists and say that they're not looking at the obvious. It's something that they are not familiar with. Uh they feel that it's really the purview of the primary care doctor to look at the patient more holistically and refer for a sleep study. It's not their issue, their problem. Okay. Um unfortunately, a lot of the subspecialties feel that way. So, for example, a GI doctor notices when he's doing an endoscopy that the patient is sedated, he has anesthesia with him to look after the airway, and uh he notices that the patient's oxygen saturation went down really badly. Uh they had to bag him and uh he recovered, they did whatever procedure, the endoscopy, the colonoscopy, and they tell the patient, oh, by the way, we think you've got severe sleep apnea. Um, why don't you go back to your primary and get a referral? Uh they will not take it upon themselves to make the referral. So GI, um cardiology, endocrinology, diabetia and its management, etc. All of this is being orchestrated by the sleep apnea. Sleep apnea causes increase in uh sympathetic tone, it causes hypertension, causes cardiac arrhythmias, causes elevated blood sugar, elevated cortisol levels, adrenal fatigue uh has been address you know, has been uh uh purported to be as a result of sleep apnea as well. So all these different subspecialties are expecting the primary. And the primary is just overwhelmed. You know, uh he is looking at different, different systems, he's trying to collate all the notes that are coming in from the different subspecialties and make sure that there's no medication interactions. But maybe he's not really addressing sleep apnea. If you look at the COVID experience and you look at the experience in the ICU, you find that a large percentage of the patients that end up in the ICU actually have sleep disordered breathing. Or disordered breathing that's present during the day, but then it becomes much more apparent when they're in the ICU. And uh we we call it sleep disordered breathing, but it's actually present 24 hours a day. They're always air hunting, they're always looking for air, and uh they end up in the ICU, and then it's too late. By the time I see them, I'm kind of flabbergasted that they haven't been diagnosed or treated, and nobody's actually thought about sleep apnea, and I end up putting them on a CPAP machine or a BIPAP machine or an ASV or a uh what we call an AVAPS unit in the ICU. But I'd write I'd really like to uh fish upstream. I want to prevent them coming to that stage, coming to that uh status where they need the intensive care unit. They should be diagnosed much earlier. Uh but it's a it's a difficult situation right now.

SPEAKER_01 8:17

So this this dive into that a little bit. So I'm gonna suggest that part of it is the way our disease management healthcare system, because that's what it is, um, is very siloed. So it's set up not because people don't want to talk to each other, but they're so caught up in their own organ system as if these organs don't talk to each other. And and perhaps, as you suggest, the primary care physician is charged with connecting those dots or whatever, but they're not because they're overwhelmed. I think that's one problem. The other is maybe the payer system that um it's set up to where uh it makes it intentable for a provider to either refer uh with something that they're not completely sure is really happening, even though it might be. It's the apnea hypotnia index. You're not really looking at the non-hypoxic problems that are the precursors that that actually eventually progress. And would you comment a little bit about uh about how you think that that may or may not be the case?

SPEAKER_00 9:39

Right.

The AHI Rules That Shape Treatment

SPEAKER_00 9:40

So to make a diagnosis of even mild sleep apnea, the criteria that you have to meet is what we call the apnea-hypopnea index. It is the number of times that the upper airway is closed off, either 50% or more, to get uh hypopnea, and then an apnea is complete closure. So you have to have five of those events before you can diagnose mild sleep apnea, and before you can be treated as mild sleep apnea, they have to have comorbid illness, they have to have neurological issues, they have to have uh the possibility of uh attention problems, cognitive issues, etc., as well as possible cardiac issues. So if you have comorbid illness with mild sleep apnea, they can be treated with conventional therapy, which is a CPAP unit. Um if they're moderate, 15 or over events, then they can be treated without having a comorbid illness, and then severe is 30 or more. These criteria were really set up in 1972, um, which is a long time ago. When I was in uh my residency and training, I did not really have any exposure to sleep medicine at all. It was in my fellowship at uh UCLN at Cedas Sinai that I was exposed to this new subject called sleep medicine. It was something interesting, something easy to do. Please go through the whole fellowship and you can take your wards at the end of the three years. So I decided to train in that. But the way we were taught was basically that it was a an old obese male Pickwickian syndrome. And that stuck in my mind. And I was intent on just diagnosing older men that were overweight. But what about the other gender? What about the females? What about the adolescents? What about the children? No, those those populations were being totally ignored because they didn't fulfill criteria for the apnea hypopany index. Postmenopausal women may qualify for treatment, but a slender woman who has retronathia, uh, some some jaw abnormalities that result in apnea, they are very, very difficult to diagnose and treat uh under the auspices of the insurance right now.

SPEAKER_01 12:12

Yeah, I would I would argue even they may look perfectly normal, not even retronathic. And I I know Kristen Kimano and and um the Klikushida uh Deepak Sharastava back in the 90s looked at a series of 500 patients that I had been told that they had no sleep problem. They did sleep studies, all the sleep studies, the age I was under five, and he uh uh they looked at it and they said they really believed these patients, of which I think almost 70% of them were female, they were relatively young, they were young to middle age, and they were normal to low BMI. And so it's somebody that would never be on your radar screen as having this condition, and so that's when a briber resistance syndrome was was uh defined. But

Women And UARS Falling Through Gaps

SPEAKER_01 13:10

interestingly, they followed those patients and they knew that they needed um therapy to be because they weren't sleeping well, and they followed them, and six years later, 83% of them had still not been able to receive help from the medical system. And so those patients end up going to the primary care physician, being treated for anxiety, depression, irritable bowel syndrome, you know, headaches for dentists, TMG, TMJ, TMD problems, which are kind of the classic uh patients that look like a vision of health, but that have all these symptoms because they're healthy. I mean, they've got a healthy autonomic nervous system. I think that's where sea medicine, even though it's been defined and recognized as its own osologic diagnosis, they ignore it. I mean, it's been defined uh as a non-hypoxic, but they ignore it. I'm confused as to why, whether it's maybe the third-party payer or Medicare that's forcing the provider to opt into Medicare and say, you can't treat that, you gotta stick to the old fat male, or you know, uh, but I almost don't want to believe that.

SPEAKER_00 14:28

Well, um it's very, very difficult to diagnose a woman with sleep apnea, especially if she's premenopausal and uh the criteria are just not fulfilled. And you you try to persuade the insurance company that perhaps a trial of CPAP would be appropriate and that the anxiolytics, the antidepressants that they're on, the slew of medications that are to come down the road could all be avoided if we were to use some kind of correction for the upper airway. And it's extremely difficult to provide uh care for these patients under the auspices of the insurance right now. And the criteria that were set up were set up again, as I said, for Pickwicky and men. And they satisfy the criteria. It's relatively easy to get a diagnosis, relatively easy to treat, but those are the end stage patients. End stage is too late, right? They've already got the cardiovascular. End stage, yeah, it's too late, you know. And uh basically what we need to do is that we need to really basically fish upstream and prevent the progression of these disease process and uh be cognizant of the fact that if sleep apnea just presents differently in different genders and at different ages. The young child may uh develop behavioral issues, ADD, ADHD, uh a little bit of being on the spectrum, perhaps a

Kids Misread As ADHD Or Narcolepsy

SPEAKER_00 16:00

little bit of autism. Um maybe uh they pr present with learning disabilities and uh problems with uh behavioral management in school. Those are the children that really need to be assessed at an early stage in their lives. And uh then you think about the college students, the students that are constantly tired uh they're talking about the possibility that they may be having uh narcolepsy. And if they have REM-related sleep apnea, they're preferentially deprived themselves of that portion of sleep. And you do a multiple sleep latency test following what is essentially a normal inverted columns, a normal polysomogram, and you find that they have REM onsets. So suddenly now they're on medaphinil, uh, Wixella, etc., etc. And uh you're trying to treat them for narcolepsy, which they don't really have.

SPEAKER_01 16:56

They don't have it, I exactly. I I so let's just say regarding the treatment, let's say we're talking about a younger to middle-aged uh population. The fact that the solution is CPAP to me is ridiculous. We already know that there's low uh compliance anyway. Can you comment on what you think the solution should be? Um, because I don't believe that you would think that a 30-year-old should be on CPAP for the following 50 years, right? Because there are side effects. Um where you think the future is in really addressing as we find out that the prevalence of this problem has increased. I mean, putting aside, you know, uh Medicare and how you get paid as a physician and the lack of understanding of your specialty, what are your thoughts?

SPEAKER_00 17:53

My thoughts regarding sleep is that I think it's underdiagnosed, underappreciated. The criteria are from 1970, and uh the medical community and the dental community both really need to address the criteria. And uh the way that we diagnose it is extreme. It's a very extreme end of the spectrum uh that we're allowed to diagnose and treat. And what we need to do is to be more proactive and perhaps use different modalities so that we can diagnose people earlier and be proactive in their treatment.

SPEAKER_01 18:31

Yeah, early intervention. Um I um did a study some years ago. Um we haven't published it yet, but we're in the process of doing it. And one of the uh PI's uh primary investigators is uh Umokatwag, who runs a sleep lab at Harvard, uh pediatric sleep lab at Harvard. He's a pulmonologist in a sleep physician. And we were going over the data on these kids, it was 50 kids, and and I was showing him using high-resolution pulse oximetry and then treating before and after, showing how the heart rate dropped, they were in distress, their symptoms went away from early intervention um definitive treatment having to do with their facial skeleton and and their breathing. And he he said clearly the apnea hypotnia index is not capturing the real problem with these kiddos, and that it's a problem. It's really the autonomic nervous system is over-regulating, it's overshooting because gas exchange is the most important moment-to-moment function in any mammal. And if there's any kind of flow limitation, you're gonna have some kind of sympathetic response, albeit maybe low, but it's chronic. And that's what leads to chronic disease. And I know he's really has had some institutional pushback as well as others that they just want to stick to the criteria. It's gotta be, you know, you're not really sick until your apnea hypotnia is over five. And so that's the future generation of Pickwickian male that snores. And that's it's a little bit sad, don't you think, Amidas?

SPEAKER_00 20:18

Yeah, it is sad. I'm always, you know, uh finding patients that are extremely fatigued, extremely tired, low apnea hypopny index, below the threshold of five, but then we come out with this other number, which is the respiratory disturbance index, which is uh the apnea hypopny index, the AHI, plus what we call the re-rose, respiratory event related arousals. And you add those together, and they may be over thirty, which is severe, but the apnea hypopny index is less than five, so they can't be treated uh with conventional therapy at least. And a trial of CPAP was something that I advocate to try to see whether there was some clinical improvement. You don't want to pursue a diagnosis of sleep apnea to see whether there's uh improvement by doing something really dramatic. So using a CPAP unit on a loner basis to see whether there's clinical improvement seemed like a good solution. But I understand now that we can use the uh esophageal pressure balloons as well to get a much higher index, and that has enabled more patients to get treated.

SPEAKER_01 21:35

Yeah, that that's been my go-to because that was the original way of really measuring flow limitation back in the 70s. Kristen Cuvenau wrote about that, where and and ironically, it was in the pediatric community. He was actually actually doing a big study looking at kids, and he used the esophageal probe to look at flow limitation. Now I think it's very difficult to get that. Because it's invasive, it's not. Um, except that no one's gonna pay for it. You have to have that special training in the sleep labs. They just they just don't want to do it, and I think that's been frustrating. But you find patients who have an AHI of 1 or 0.5 when you use a sulfageal uh probe that is able to pick up those flow limitation nuances that have a hypopnee index goes up to 30 or 40 really shows what's going on. Um, and if that helps the patient get attain a letter of medical necessity for the insurance company by contract

CPAP Limits Compliance And New Concerns

SPEAKER_01 22:40

to be forced to help pay for the treatment, I think it's it's um it's worth it for the patient, but it's sad that you would have to go through that. I I don't know what the solution is. I am concerned with long-term CPAP, with the recent studies in the last two years that actually shown that due to pneumatically stinting the airway open, there's an upregulation of um uh angiopoetin, which is uh cardiovascular risk, it downregulates veg F, which is cardioprotective. And so I don't know where we are on the studies actually trying to suss out what's going on there. I don't know if you've read that or have heard that, but that long-term use of CTAP can be harmful. And one of the reasons perhaps that they didn't find a big change in cardiovascular changes in cardiovascular mobility, mobility. Yeah, it part of it is there's only 30% um compliance, right? And then when they use it, it's the first half of the night versus the second half, right, when it's most risky. But maybe some of it also is are these cardiovascular um regulators that may be harmful because you're stinting the airway open and it causes the stretch receptors to release these um these factors that turn out to be um cardiovascular risks. But I I don't know what your thoughts are about that.

SPEAKER_00 24:08

Yeah, I haven't read a lot about that uh right now. And um I know that uh there's been uh studies done on CPAP usage, compliance, as well as whether it reduces cardiovascular uh mortality and morbidity, and uh there is really no good medical evidence for CPAP usage, except the patients do feel better if they use it. Yeah.

SPEAKER_01 24:33

Some of them do. Yeah, that was actually published uh in the New England Journal of Medicine. They did a follow-up to the Wisconsin cohort looking back, and that's what they found. Uh they found that it was related to hypertension as well. Um, but um, yeah, I I I don't know what that solution is for for me as a dentist. Um, I want early intervention. And if you really understand the risks to our children very early on, having to do with uh the all the things that you listed, the cognitive uh uh problems, the ADD, ADHD, which really they don't have. It's just they're not sleeping. Sleeping, right? And and uh Dr. uh Gozal, David Gozal, who now is at um physician-in-chief in West Virginia, um actually showed um that the immune system um get takes a hit and the cancer incidence goes way up as a result to just sleep fragmentation. And he actually, uh he and others, Nieto from Spain, have actually said that obesity is causal for cancers. And obesity is really a finding of long-term um sleep breathing problems. It's not the cause of it, and yet sea physicians oftentimes say that lose some weight, um, you're gonna do better. I think you're gonna do better, but it's I don't believe that it's the cause. Um, I believe it's a comorbidity of the individual being in chronic low-grade um breathing problems and upregulates sympathetic drive. Um they become fat, right? They aren't born fat, and it's not just the food supply. I mean, it doesn't help to have you know the food supply that we have, but um because I know when I treat my patients, they do nothing different, else different. I see them a year later, and they've just dropped the weight without being on a GLP1. So um I don't know if you've you've noticed that if patients get on CPAP, you notice that they probably well they have a drop in their sympathetic tone, for sure.

SPEAKER_00 26:56

For sure. Uh the adrenals are not being constantly stimulated by the apneas, and they're not constantly releasing cortisol. So it's not just uh an adrenal issue in terms of release of uh uh sympathimetics. It's it's basically a question of cortisol release as well, and that can be alleviated by treatment of the sleep apnea. So weight loss does follow treatment.

SPEAKER_01 27:22

Yeah, yeah, that's um because you regulate metabolically. It's during N3 sleep that the hypothalamus releases glucagon, insulin, the sex hormones, growth hormone. And if you're not getting enough N3 sleep, you're not releasing it because it releases it in spurts of suddenly nine minutes, three to five times a night. You're just not getting it because it's um what what do you um see? Tell me what you think about this. Um I believe it was Steve Park and and others have actually uh stated that, and and there are others that have stated that women

Metabolism Weight Cortisol And Pregnancy

SPEAKER_01 28:00

in the third trimester of pregnancy, almost all women um have sleep disorder breathing. And it makes sense because it's kind of like the hypoventilation from having this big mass in your belly, just like you know, the Pikwickian male, and they are very uncomfortable. So they're moving around trying, and and there are studies to actually show that the cortisol that results from that has downstream consequences to the fetal, uh to the fetus, um, small for gestational age, increased risk of preclapse, you know, increased risk for gestational diabetes. I, when I talk to uh a mom that's pregnant in the third trimester, I suggest that they should either have um an oral appliance or CPAP temporarily during that period. What are your thoughts about that? Does that make sense?

SPEAKER_00 28:55

That makes a lot of sense, actually. I saw a patient uh about a week ago that had been referred, and uh the funny thing was that she was at risk already because her father has sleep apnea. And so uh genetically she was predestined to have sleep apnea. It just came on faster with the pregnancy. And one of the one of the issues is that um she had had a previous pregnancy and had also suffered from eclampsia where she had not been treated. On this occasion, she wanted to be treated aggressively. CPAP, whatever, dental device, just so that she could go through the pregnancy and not have the complications as a result of the sleep apnea exacerbating eye hypertension, as well as you know, having a more riskful sleep for sure.

SPEAKER_01 29:43

Yeah, I I don't um I yeah, I it um yeah, that makes sense. Now, we're friends, so I don't want you to get mad at me when I say this. Um but I'm gonna argue and push back that there's no evidence to support that if a parent had a grandparent habit that you have that's actually genetic. I uh believe there's strong evidence that's epigenetic that you acquire this condition. Um we never had this condition, you know. Well, first of all, obesity was relatively non-existent two, three hundred years ago. It really wasn't. We changed our food supply and all that. But I think we tend to say things are genetic because they run in families. But I think also what runs in families are, you know, cultural norms of this is the way you eat, this is what you do. Um, yes, you might have similar facial skeletons because you look like your parents, um, but there is a lot of evidence to show that it that the way we are developing um has changed dramatically in the last 500 years, and that results in smaller nasopharesis, smaller uh airways that are risks for flow limitation on that. I don't know if you have a comment on that or what your thoughts are. Because you're kind of strict critical care physician, right? Right. Yeah.

SPEAKER_00 31:09

So I have I have my thoughts about you know diets and GMOs and you know uh extraction of teeth, extraction of wisdom teeth, extraction of premolars to get that perfect smile.

SPEAKER_01 31:22

Don't let the orthodontist hear you.

SPEAKER_00 31:25

But it's it's I think we're predisposing ourselves uh

Jaw Growth Breastfeeding Orthodontics Airway

SPEAKER_00 31:30

to uh all the chronic problems as a result of sleep apnea by not addressing these issues at an earlier age. We need to address things a much, much earlier than what we're doing right now.

SPEAKER_01 31:43

So if we could just follow that line of uh logic, because it totally makes sense. So if we're extracting teeth, let's say you're an orthodontist, you're extracting teeth to straighten the teeth out, why not ask the question why there was crowding to begin with? Because there's no set of alleles that call for dental crowding. So down crowding is really a solution for mother nature to a problem, which there wasn't enough development of the arches, there wasn't enough growth. Um, anthropologically, we go back, it just never happened in any population anywhere around the world unless it was a diseased population, usually the bourgeois or uh the very wealthy that had a lot of um a lot of wherewithal that was kind of westernized, that didn't allow for good growth and development. Um, but we just never saw it anthropologically. So doesn't it make sense if you're extracting teeth? Maybe the problem already existed, but it was subclinical and not recognized, and then you make it worse by retracting, and then now you have even less airflow. And so that's the way I think of it is that it's it's really treating a symptom, chasing a symptom that makes an pre-existing condition even worse. Right. I remember this study, this may be similar, and this is what we do, and sometimes in evidence-based reductionist thinking, there was, I remember a physician was well-known physician, who was on TV talking about a study that had just come out saying that the use of diaphen hydramine for sleep that people will use as a sleep aid had been associated with an increased risk of um Alzheimer's or presenal dementia. I remember thinking about that, going, hmm, isn't that interesting? Isn't it maybe possible that the reason why they had the Alzheimer's is because they couldn't get good sleep and they were taking a medication to get them to go to sleep, and what ended up happening is it just played out. So they're making this association of a medication creating the risk, but it was already there, and the patient was just trying to solve a problem, which was to sleep, but they weren't able to sleep for whatever reason. That makes sense. Maybe it's a little bit of that. We have to be careful, but right. The chicken or the egg situation. The chicken or the egg, right.

SPEAKER_00 34:25

Right. And um I think that developmentally, uh children who are not given adequate uh feedings, breastfeeding, for example, is much more uh laborious for the infant than is bottle feeding. Yes. And uh d jaw development is affected by what type of food the child gets, whether it's uh breast milk or whether it's um artificial milk. And so I think jaw development is affected, especially in the Western countries, which have a propensity towards uh feeding the children uh non-human milk, basically.

SPEAKER_01 35:11

But do you okay, so do you think it's what's actually in the milk or is it the action of how you draw the milk?

SPEAKER_00 35:16

I think it's the action of drawing the milk.

SPEAKER_01 35:18

Exactly. Yeah, right. People people it it's it's less about what's in the food, although that's important, but you have to challenge those muscles very early on, and then it starts stimulating you know compensations, and I say it's this downward spiral, and you go to soft foods, and then they have texture version, then they only want to have chicken tenders and fries, but but uh um Dr. DeSova, tell me what what would be your nirvana as far as like what would you like to see, you know, as a uh pulmonologist critical care sleep physician, what would you like to see if you could change the system that you think would help the public's health in general as it pertains to um sleep apnea or sleep disorder breathing?

SPEAKER_00 36:04

I think uh from an uh epidemiological situation or making a huge change, I think that we should go back towards uh breastfeeding. I think that's one of the major, major issues. Uh breastfeeding, I think, would improve jaw development, uh musculature, etc. etc. Um I think dentists are much more aware of sleep apnea than some physicians are. And uh that is because uh they see the airway all the time. And I think they're cognizant of the fact that they may be making things worse by extraction of teeth. Um and so uh I think that I don't like using jaw expanders very much because I think it's very uncomfortable for the children. But on the other hand, if you can prevent long-term complications um by using the jaw expanders, they're really not uncomfortable at all.

SPEAKER_01 37:00

No, they all they don't have any discomfort. In fact, they find a relief. As soon as you put it in there, they kick and scream for a few minutes, and then uh I'll see them even a week later, they they don't even know it's in their mouth. But mom will say, Oh, he's not tossing and turning, he stopped the bed wetting, you know, he's not sweating, he's a different kid in the morning. He gets up. So, yeah, I mean, I think that uh I mean you would think it would be, but it's not uncomfortable. It really isn't, Dr. DeSova. Um, and and if it has lifelong consequences. In fact, I think when we were in the green room, you were telling me a story, a couple of stories that if maybe you could share regarding um uh a couple situations where patient came in and was upset at you, and and uh could you tell

Two Patient Stories That Changed Practice

SPEAKER_01 37:50

us you know what I'm talking about?

SPEAKER_00 37:51

Yes. So um the way that I was educated, only adult men who are overweight have sleep apnea. And uh there was this lady that came and met me at one of the clinics and was determined to get a sleep study for her 15-year-old son. And what was the complaint? Well, the complaint is that he won't get up for his Saturday job. He won't go and work at Jack in the Box on Saturday morning. It's very difficult to get him out of bed to get to school, very difficult to get him to get out of bed to go to his job. He just will not get up. And I was not in a a mindset where I was going to accommodate her by giving a sleep study to a 15-year-old, especially when I knew I was had been trained that it was going to be a obese older man that was going to have sleep apnea. I left her in the room, I went around, saw all my other patients, came back again, she's still there, went, did another round, came back again, she's still there. On the third round, I relented and uh ended up actually ordering a sleep study on a 15-year-old, which was so much against what I had been trained. And it came back, and it wasn't just mild or moderate, it was nearly severe. It was 25 apneas and hypopneas an hour and uh I was just overwhelmed. I could not believe that I could be so wrong uh clinically that I didn't suspect that he had sleep apnea. Treated him, put him on a CPAP machine, and this young man just disappeared um and I didn't see him for a long time. And uh I was coming out of a movie theater uh after having seen a movie called Fast and Furious, and it was at the time that there had been some assaults in the in the movie theaters. So I was coming out and I get accosted by a group of teenagers and I'm feeling rather fast and furious myself at that time. And uh I was getting ready to have a confrontation, and these individuals said, No, no, no, don't don't get upset. Uh this young man is actually your patient. Uh huh. And I didn't fully recognize him. And uh subsequently I found out that he had uh gone to one of the university centers and had magzillafacial surgery for his sleep apnea and he had a tremendous improvement in his educational uh trajectory. He had been failing everything, not being able to get up, he was falling asleep at school. Suddenly treatment had resulted in an acceleration of his intellect, uh he was now in pre-med and he was going to do medicine and actually start uh to do sleep medicine. That was his that was his aim in life. And I was just uh overwhelmed that uh treatment which I thought was a relatively minor, you know, minor intervention could have such a profound effect on a person's educational trajectory and their achievement in school. Um was not aware that that could have such a profound effect. And since then, since that I suppose intervention by his mother on my treatments, I'm much more open to uh evaluating younger children, adolescents, even younger females, in terms of their sleep and their sleep disorder than I would have been if I hadn't had that experience.

SPEAKER_01 41:25

Yeah, wow, that's that's uh in my experiences, I I have those stories almost every day in my staff. Some of those uh there are days where people are crying. Patients come in, super rewarding, but at the same time you people could be angry. Yes. How the how was that missed?

SPEAKER_00 41:44

How was that missed? So another another story, uh not a very pleasant story for me, but I had a patient that came in with end stage uh colon cancer, it was metastatic. He had hematemesis and hematochesia, and he was found to have metastatic colon cancer. And uh the liver was full of it. So I needed to talk to the family. I gathered the family and I was talking to them. And the oldest son would fall asleep during this very, very important discussion, and I felt kind of hard done by because he wasn't actually listening to what I was saying. Anyway, at the end of the conversation I told him, Look, I can help you, but I can't really help your dad. And um I organized for uh this patient's son to end up getting a sleep study. And I was very enthusiastic uh when he was going to come into my office, really wanting to see what the outcome was. And he came in and uh I hugged him and said, you know, how how's things going? And he says, They're going terribly. So I said, Why? You know, I'm so sorry about your father. He passed away and he said, No, no, no, it's not about my father. It's about me. So I said, Well, tell me what happened. He says, Well, I've been complaining of sleepiness and uh being unable to stay attentive at school since about the age of fifteen. I'm now thirty-five. I come in to see my father who's passing away. You look at me for like two minutes and you say, Oh, I know what's wrong with him, I can treat him. But where were you twenty years ago when I needed you? I didn't pass my educational uh goals, I didn't get my GED. I work as a janitor, and I'm at risk of losing my job because I keep on falling asleep. And it's just it was heartbreaking. And he was crying and angry because of a lack of diagnosis. And that's what we're facing right now.

Fishing Upstream Final Takeaways

SPEAKER_01 43:55

Yeah, yeah, it's poignant. Yeah, it's it's I I think our responsibility to our patients, but the population at large has to refocus, has to refocus on a bigger picture beyond, as you say, that Pickwickyan fat snoring male who don't want to be on CPAP anyway because it doesn't bother them that they're snoring, it's just their bed partner. Um, it's the next generation of chronic disease. And and um Dr. DeSovai uh I uh really appreciate you coming in and um participating in this podcast. Um I have a lot of respect for you. I know um you're an excellent sea physician, you really care about your patients, and you know, we've become friends through the years, and and uh I'm gonna continue to collaborate with you. I want to continue to try to change the environment, make it easier for other providers first to understand, and then also to work within a system that's somewhat broken. Um and I know you've got so many interesting stories in the ICU as well, and I know you went through hell during COVID. So I'm so glad that that's over and that you are focusing more on sleep medicine because I know critical care will grind you up and spit you out. And you deserve to uh practice for a long time. So thank you very much for that.

SPEAKER_00 45:23

Thank you. Yeah, appreciate it.

SPEAKER_01 45:24

Thanks.

SPEAKER_00 45:24

Thank you for inviting me.