Sleep Apnea Isn’t What You Think: Dr Dave McCarty on Breathing, Sleep & Personal Empowermenthttps://traffic.omny.fm/d/clips/1306acca-8e91-407b-adba-adf70057d15f/773041ac-0ce2-41e4-9337-ae11015b73d3/3cfa8881-d357-4b0c-b466-b44400532783/audio.mp3SHOW NOTES 𝗪𝗲𝗯𝘀𝗶𝘁𝗲:Empowered Sleep Apnea
𝗕𝗼𝗼𝗸
Empowered Sleep Apnea: A Handbook for Patients and the People Who Care About Them – co-authored with Ellen Stothard, PhD.
Organizations / AffiliationsSpeaker at the 22nd Sleep Education Consortium Conference.
Guest on multiple podcasts discussing:
Blog: https://www.empoweredsleepapnea.com/daves-notes
Courses & Education: https://www.empoweredsleepapnea.com/learn
Podcast: https://podcasts.apple.com/us/podcast/empowered-sleep-apnea/id1643770403
00:00 Intro & Importance of Sleep
02:10 Sleep Apnea Explained
05:00 Obstructive vs Central Apnea
08:15 Problems with Sleep Labels
10:50 Facial Development & Breathing
14:14 Five Reasons to Treat
19:56 Apnea, Hypopnea & Hypoxia Definitions
23:00 ADHD & Sleep Connection
31:14 Patient Empowerment
33:48 Five-Finger Framework
43:26 Narrative-Based Medicine
51:06 The Nose Rules & Nasal Breathing
54:26 Nitric Oxide & Oral Microbiome
56:08 Final Reflections & Outro
Sleep Apnea Isn’t What You Think: Dr Dave McCarty on Breathing, Sleep & Personal Empowerment Dr Ron Ehrlich (00:05)
Hello and welcome to Unstress Health. My name is Dr. Ron Ehrlich.
Well, today we are exploring possibly the most important part of the day, and that is how well we sleep. It sets us up for not just the next day and how well we approach it physically, more mentally and physically, but it also lays down the foundation for every aspect of physical, mental and emotional wellbeing.
Sleep apnea, for example, affects close to a billion people worldwide. Yet most people feel lost the moment they receive a diagnosis. Well, Dave McCarty is my guest today and I’m welcoming him back. He’s a sleep physician, an author, and a creator of empowered sleep apnea. I don’t, we love that word empowered. I mean, if I was looking for a mission for unstressed health in the word empowered for you to be empowered would be it.
It’s a platform sent powered sleep apnea is a platform dedicated to turning confusion into genuine understanding and importantly, personal agency. Now Dave’s approach is quite unique and inspiring, not only with cartoons, which he illustrates himself, not only with storytelling and cold hard science, Dave is rewriting the way patients and practitioners navigate this complex condition.
I hope you enjoy this conversation I had with Dr. Dave McCarty. Welcome back, Dave.
Dr Dave McCarty (01:35)
Great to be here, Ron. Thank you.
Dr Ron Ehrlich (01:37)
Dave, with some of my guests, not all of them, I love to get them back regularly. And I love getting you back because not only have you got such an important and powerful message, but sleep is so fundamental.
In fact, one of the, sleep sleep apnea, which I know is something you focus on a lot is often described as a simple problem with a simple solution. you, yes, I thought it would get a laugh out of you, but your whole project says, otherwise, can you walk us through the many moving parts of sleep problems.
Dr Dave McCarty (02:10)
You know, I would love to, Ron, because I think that’s the biggest misconception. Once you name something that the human desire is to, I think it’s very simple. And so let’s just talk about that term, sleep apnea, right? The word apnea means not breathing. And so if I go tell somebody that they have sleep apnea, that means I’m not breathing when I sleep. And it’s a nonsensical idea. Of course you’re breathing when you’re sleeping.
So this is a jargon term that means something else, right? So what does it mean? It means that the breathing is not stable during sleep, right? So it’s unstable breathing during sleep that affects one’s health. Now we’re getting somewhere. Unstable breathing during sleep that affects your health in a negative way. And by the way, that unstable breathing can happen for two reasons.
One is obstructive sleep apnea. the airway can get obstructed when we’re trying to breathe. So breathing against a closed or a semi-closed airway, also known as choking, right? Choking. So that’s one reason the breathing can be unstable. But the other reason the breathing can be unstable is the physiology is similar to the pause in breathing that might follow several large deep breaths.
So if you took a very heavy sigh, for example, you might find that you could sit there and wait for a long period of time before you felt like you needed to breathe. Right? So that’s a different flavor of instability. And that flavor of instability of breathing is called central sleep apnea. Okay. So now if we have the concept that sleep apnea is actually unstable breathing during sleep, that negatively impacts health, that can happen for obstructive reasons or central reason. And then if we have the idea that, why does the obstructive sleep apnea reason happen?
Now we get into the many moving parts. So it happens for lots of reasons. It might happen because, well, this person, for example, happened to breathe with their mouth open and their tongue happened to fall back because their nose was a little too blocked. That was their reason. Another person’s reason might be because they’re very heavy. And so there’s a lot of extra heaviness here too. And so the reasons can actually be listed. Same thing is true on the central sleep apnea site.
So if we accept now that this is unstable breathing during sleep that negatively impacts health, that can happen for one of two reasons, obstructed bar central, and each of those reasons has many moving parts. And now we think this instability can be fluid across time, space, and situation. So, you know, if you take a person with a certain type of breathing pattern at sea level and put that person at 10,000 feet, the instability will change.
It will be a different flavor of instability. So we get the notion now that labeling someone is sort of an exercise and well, it’s just a snapshot in a very complex moving picture. So the concept that I’m trying to get across with this empowered sleep apnea idea is that the word sleep apnea is always sort of a gateway. It’s an entry point. People wanna talk about it.
Hey, I heard I might have sleep apnea or I screen positive on my Apple Watch or sleep app. It’s just an entryway. It doesn’t really tell you what it is or what to do about it yet. It tells you that there’s unstable breathing during sleep and you got to question what you might want to do about it. But it really opens the larger question of why is this happening to you? Which moving parts are relevant for you? Because obviously you’re the person who’s going to have to decide to do something about that. So it’s a big question. Thanks for leading with that.
Dr Ron Ehrlich (06:02)
Yeah, look, it’s an interesting one too, because in order to solve a problem, if there is one, it always helps to know what that problem is. Yes. I mean, I know that sounds so obvious, but we do rush off to solve a problem before we’ve completely identified it. And yet people, it’s a bit like breathing, isn’t it? Look, I’m breathing. I mean, what more is there to breathing than breathing? I mean, for us who are involved in this professionally.
We understand there’s optimal breathing and there’s dysfunctional breathing. But for how many, the 95 % of the population, I’m breathing. I’m alive. What’s what more is there to it? I sleep. This is the way I’ve always slept. It’s no big deal. mean, that is the probably one of the biggest hurdles, isn’t it? For people to realize, and this is why I love your word in power.
Dr Dave McCarty (06:54)
Yeah, well, it’s a question of where you fall on a spectrum rather than a binary anymore. And that’s problem with language. ⁓ We started this journey understanding about what is sleep apnea based on the narrative of the so-called Pickwickian patient, you know, the very heavy person who snores, who is sleepy in the daytime. That’s a specific picture.
And that’s where we got the notion that sleep apnea even exists. That’s the first type of ⁓ category we got. But the further we waded into the diagnostics, the more we realized that you don’t have to be heavy and you don’t have to snore and you don’t really have to even drop your oxygen levels anymore. So just has to disrupt your sleep. So the definition of sleep apnea has changed to be something that no longer even requires you to stop breathing.
You just have to have unstable breathing that affects the quality of your sleep. So this language has sort of tried to expand to contain a beast that it’s just that that term is too small to contain it. And all that means is if we say sleep apnea, we need to have a method of opening it up to talk about what that term actually means because the visual picture is such a large spectrum that it doesn’t mean anything.
Dr Ron Ehrlich (08:15)
I mean, you are a sleep physician and it’d be interesting to put this in perspective for us that you’ve identified these two areas, obstructive and central. So for every hundred patients that comes through your door, what proportion of them suffer from obstructive and what subject subjects suffer from central? And is there a combination of the two?
Dr Dave McCarty (08:38)
That’s a great question and I’d like us to think about these two physiologies as independent but they also have a way of communicating with each other. So it’s a trick question because I’ll say all of them have both potentially depending on how you’ve kind of twitch those variables and this is true because altitude is a pretty dramatic accelerant for central apnea physiology.
So you take a situation like a CPAP mask, right? That’s gonna help with the obstructive flavor. And up here in the mountains though, that CPAP mask is a little more likely to push you towards the hyperventilation side of things. A little more likely to help you overventilate and create that unstable breathing pattern that we all call treatment emergent central sleep apnea or TEXA. Okay, so these labels
They come in handy because they help us categorize things. I’m afraid many times the labels just kind of run away with the show and you see someone’s chart and it says obstructive sleep apnea G47.33. And what crosses your mind is that’s the only thing going on with this person. Right.
And of course that’s foolish because if you took that person and put them at 10,000 feet, of course they’d have central sleep apnea. So we have to start thinking of these things a little more physiologically and a little more fluidly and get ourselves away from the trap that those labels impose on us cognitively.
Dr Ron Ehrlich (10:08)
You mentioned obstructive having a couple of different drivers and obesity, blocked airway allergies. ⁓ and, and I, I’m guessing we should also include narrow jaws and crowded teeth. I wouldn’t be, you know, and when I think about the proportion of population that a could be a little obese, that B may be a little bit sensitive to some of the many environmental toxins of out there.
And C, considering 95 % of the population don’t have enough room for all 32 of their teeth. I mean, this must be a huge and undiagnosed problem.
Dr Dave McCarty (10:50)
Well, is. It’s hugely undiagnosed, but I think we’re getting close to overcoming that barrier because of all the wearables now. It’s not going to be long before you can get this diagnosis by simply buying something at the Best Buy or whatever the technology store is. My concern is what are we going to do with this new label once we get it? Because it really does need to be unpacked.
As you said, there’s many moving parts and one of them is the jargony term is the crania facial respiratory complex, right? That’s the bony and soft tissue constituents that compose the upper airway. And the narrative now is that the development of our face is just different than we were genetically programmed to achieve. So our pre-industrial forebears, as you mentioned, had room for all 32 teeth.
And even the wisdom teeth quote unquote erupted in front of the ramus, right? That’s interesting. And that means that ⁓ the width of the face, that ⁓ the lateral dimensionality of these faces was larger and the depth of the face was larger. And so it doesn’t take, you know, a real sort of architect to understand that the tongue that’s sitting in there and all of that soft tissue stuff and the, with the roof of the mouth being the floor of the nose that architecture makes for an easier time of nasal breathing, right?
So once we sort of recognize that genetically, we could achieve a different size and shape of face, and that it actually could contain all of our teeth, that has a direct impact on the size and shape and function of our airspace and our airway. And that’s a new revelation for many of us, because we think about, you know, why is our teeth crooked? Well, it’s because we need braces because we need orthodontia, know, orthodontia.
So straight teeth. And the truth is possibly a little more complex than that, that the reason these teeth are crowded is because the face hasn’t really developed this way and this way. And there are ways to reverse engineer that. So we can spot that earlier now in kids. And for adults, there’s ways to sort of widen the palette. Marpy is one technique, but there’s evolving field engineered techniques about how to make the facial architecture a little bit more like our pre-industrial forefares so that we can actually breathe through our noses better and sleep better.
Dr Ron Ehrlich (13:26)
As someone who’s been in practice or had been in practice for over 45 years and who very enthusiastically embraced orthodontics and orthopedics with that in mind, it didn’t take me long to come to the conclusion that while there were many benefits to that kind of treatment for those that chose it, thank goodness, the human being is more adaptive than, know, you either get the dental treatment or you’re stuffed for the rest of your life.
Fortunately, that’s not the case, but it definitely helps. Now you talk about five reasons for treating. think you talk about risks, snoring, sleep, comorbidities, reframe the question to why treat this whole conversation. Can you take us through those five reasons to treat?
Dr Dave McCarty (14:14)
I’d be delighted. This is the step. It’s kind of like the, you have a timeout step before you saw someone’s leg in the operating room. This is the step that says, why are we doing this? If we, if we make the statement, okay, Ron, you’ve got unstable breathing during sleep and we think it’s affecting your health. Then the next step is why should Ron Ehrlich stabilize this unstable breathing pattern? What, what, what’s in it for you? Okay.
And so the five reasons to treat them, in I’m wearing my button here. I don’t know if you can see that, but this is from the Empowered Sleep Hapnia Project. five reasons to treat are risk, snoring, sleep, wake and comorbidities, as you said. Risk is first because it’s a timeout. It’s the hardest one to actually talk about because we can’t really get away with using labels like mild, moderate and severe anymore to drive the conversation.
This is the hard part. We want to so bad because it’s so easy. But the problem is these labels can be misused, misapplied, and they can actually cause harm. I’ll give you an example. Let’s take an 80-year-old woman who has kind of a narrow face, so she’s got a blocked nose, and she’s also got restless leg syndrome. And we move this woman up to 8,000 feet above sea level.
So now she’s got a little blocked nose, so she’s breathing with her mouth open. And every 30 seconds, she’s got one of these periodic limb movements of sleep. Right? So it causes a brief arousal and during that arousal with her mouth open, she’ll go, and then following that, there’ll be kind of a pause or a reduced effort and oxygen goes up and down. Okay. So we have an unstable breathing pattern. We can see deviation in oxygen and she will have
In this fictional example, she’ll have lots of hypopneas, lots of under breathing events being scored. And hypopneas by definition are neither designated, neither obstructive or central because it’s hard to do that. So we don’t have to. So she would have a lot of hypopneas and she might have enough hypopneas per hour that maybe even 30 or 35 per hour. Now she’s being told you have severe sleep apnea. And this is before she’s even mentioned anything about how she’s feeling, right?
So I’ve seen this scenario play out. This is a person who probably wouldn’t do well on CPAP. So now she’s a CPAP intolerant, severe sleep apnea. So now you get the idea. And then now there’s ever more drastic things being lined up in the name of defending her against this severe disease. Meanwhile, we really don’t have any sort of evidence to show anyone that central hypopneas caused by this mechanism are dangerous, right?
So it starts to get the cart way before the horse if we use language like that. So instead of the mild, moderate, severe, how do we do it? Well, we try and break down, is this an obstructive problem or a central problem? We try and figure out how frequently those events are happening. We can see how deeply the oxygen is desaturating. So there’s something called the hypoxic burden.
So different sort of flavors of figuring out, is this the flavor of sleep apnea? that’s going to cause harm because we have pretty good data from our population-based cohort studies that obstructive flavor events are pretty bad for you. The more frequently they happen and the more deeply they cause the oxygen to drop. That choking, that trying to breathe against a closed or a semi-closed airway is pretty physiologically alarming.
You know, it’s called choking. And so there’s a different degree of physiologic stress that comes from the obstructive flavor compared to the central flavor of events. And just breaking this part out and recognizing that it’s not the same for everybody, and we need to talk about whether this is the flavor of sleep apnea that’s going to hurt you.
Sometimes it’s not clea and so in our current clinical project called Rebus, we offer advanced and blood work testing to take a look at some of the cardiometabolic risk factors, markers, if you will. So this woman that I’m talking about, this fictional patient up in the mountains, she could be absolutely a vascular perfection. She could be the type of person who’s running ultra marathons in the mountains and she’s still got this AHA of 35 because of the central event.
So is this the type of thing that we should offer her stabilization for in the name of risk, right? Sometimes it’s hard. And if you do blood work and her blood work all says, hey, this person is metabolically tranquil, this looks beautiful, there is no inflammation, cardiometabolic markers are down. We can say, know, hmm, maybe risk is not a reason for us to stabilize this and we can move on from it.
Okay, the point of it being the first step of the process is to call attention to it’s not easy and it deserves pause before you start bossing people around by virtue of what their members are.
Dr Ron Ehrlich (19:42)
Now, Dave, just let’s just remind our listener very quickly to give us the couple. You mentioned a couple of words there, our listener may not be as familiar as you and I are apnea, hypopnea and hypoxia. Give us those 101.
Dr Dave McCarty (19:56)
Yes.
They’re great jargony words. So apnea, as we talked about at the beginning of the program, means not breathing. And so an event where there is no airflow at all for a certain period of time is called an apnea and you score it. A hypapnea, that word means under breathing. So it just means several breaths that are a little too small to get the job done. And it causes instability in oxygen or something, and it causes stress. So they’re not breathing enough.
At the end of it, there is usually recovery breathing, at which point things come back into shape and perhaps there’s an arousal from sleep or an awakening or a movement or something like that. The word hypoxia just means a drop in oxygen levels in the bloodstream. So if your breathing is interrupted to where out of a reason, the blood oxygen level tends to go up and down and that instability, the body doesn’t like that. It really wants for things to be real stable like that. Thanks for clarifying that.
Dr Ron Ehrlich (20:58)
Last definition, just to put our listener in context is the reference to AHI index. You mentioned 35 of those, a score of 35 is severe. Remind us again of what an AHI index is.
Dr Dave McCarty (21:14)
For sure, yeah. So this is just tallying the number of these events that you can see per hour. So it’s an event rate. So the apnea hypopnea index is one of the most common metrics that’s used to say, bad is this problem? How many events per hour are you having? And we’ve gotten into the habit of using benchmarks to say, well, this is mild, this is moderate, and this is severe. And that works for some iterations, but it
It often leaves people out or it misleads people. You know the person who has so-called mild disease You know by virtue of an AHI of five or six that person may really suffer from that and and so the mandate to Straighten that out for that person may be very high based on the other four reasons to treat so let’s just go through them Yes, we talked about risk risk is first because that’s the hardest to talk about but snoring
I call that out as an independent reason to treat because it’s specific for sleep apnea. It’s a cause of a lot of nuisance that people are afraid to talk about. And it’s also a way to explore something that people might not know themselves. So if you say, snoring is a reason to treat because, you know, the rattling of the all of the tissues up here, we think that’s one of the reasons why people who have sleep apnea have a higher risk for a stroke is that all of these tissues are very close to the carotid arteries and it can cause damage to the lining of the arteries when you’re sort of rattling those tissues with such profound energy over and over again.
Snoring causes social consequences. So we’ve heard of the sleep divorce where people have to go sleep in different rooms. So asking about it, clarifying whether someone breathes through their mouth or through their nose during the discussion about whether snoring is a reason.
I’d like to sort of bring about some of the new understanding about breathing physiology. Nose breathing is just different from mouth breathing, right? So breathing through the nose, we think tips us towards the rest and digest functions, the parasympathetic, whereas mouth breathing tips us towards the sympathetic or the fight or flight.
So if we kind of think that just that small thought, hey, if I’m breathing with my mouth open during sleep, it’s tweaking my fight or flight nervous system a little more than it should, maybe that’s one of the reasons why I’m not sleeping well. Okay, so second reason to treat snoring allows that whole discussion and that discovery to happen with the patient. Third reason to treat is the sleep experience. So this just calls attention to the fact that sleep apnea does things to sleep and it can do all kinds of things to sleep. It can make you feel like you can’t sleep, for example.
It can cause frequent awakenings frequent trips to the bathroom. If you have a tendency towards some sort of other sleep disorder like sleepwalking, well, sleep apnea kind of pushes you in that direction too. We get to that when we talk again about comorbidities. an assessment of the sleep experience and is this tranquil, deep, continuous, restful, comfortable or something other than that? Fourth reason to treat is the wake experience.
So, you know, how we sleep affects how we wake. So if a person is feeling cognitively limited, decision making is tough, attention deficit type symptoms, you know, all of these, we lump them into daytime neurobehavioral impairment or neurocognitive impairment symptoms. And the hard part about this is, A, we’re embarrassed when we feel limited, so we don’t like to talk about it.
And B, we use a lot of things to compensate. So caffeine, nicotine, all kinds of stuff to do to keep ourselves awake. We might even get ourselves a diagnosis here and there that gets us access to stimulant type medication to treat that. it’s a, what is daytime impairment? That’s something that really needs to be explored with an open mind and kind of the idea that we’re looking to discover what’s going on here.
And then the final reason to treat, of course, I didn’t even mention daytime sleepiness, because that’s where we started the journey of understanding sleep apnea was abject, falling asleep during the daytime. But the fifth reason to treat is comorbid conditions. Comorbidities is a mouthful that just means other health problems. And there’s lots of them. And so there’s no complete list.
But lots of problems get worse with the nonspecific stress of sleep fragmentation, sleep curtailment, and intermittent hypoxia and the other stresses that come from sleep apnea. things like migraine headaches, bruxism, teeth grinding, high blood pressure, diabetes, blood sugars, anxiety, so mental health disorders, on and on and on. The key here is to inventory one’s own kind of list of maladies, seeing what one is working on, and ask the question, could
You out and you be making this worse?
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Dr Dave McCarty (27:44)
be more challenging to treat because of this other foundational problem, know, sleep and breathing, a couple of the foundational activities that we do. So if those are disrupted, could it be making other health problems worse? And after that co-discovery exercise, if the patient and the provider, the healthcare clinician, both sort of say, yeah, you know, you’ve really got some reasons to get in there and try and stabilize this like you mean it, then what happens next is whatever one tries as a treatment or stabilizing strategy, we’ve now got built-in goals about what we’re trying to achieve.
So we know if that treatment is achieving our goals. That’s, think, one of the most important steps here is it puts the agency back in the patient’s ⁓ control, that they know why they’re doing this, and they’re going to know when they’re there. They can escape from the fear of doing a treatment because they’ve been given this scary label and now this person in a white coat needs to tell them what to do.
Dr Ron Ehrlich (28:48)
Hmm. It’s interesting, Dave, because we’ve done a program with pediatric respiratory physician, Jim Papadopoulos here in Australia. And he said something which was quite surprising, shocking in fact, and that is that 50 % of children diagnosed with ADHD have an undiagnosed sleep disorder breathing condition. And when, and when I think about the number of adults, because this is becoming a very, common and I might add a very popular diagnosis for adults. ADHD. I’ve got ADHD. This explains so much. And my doctor gave me Ritalin. And guess what? I’m getting so much more done. Not surprising.
Dr Dave McCarty (29:34)
Yeah. Yeah.
Dr Ron Ehrlich (29:38)
As a sleep physician must be wondering hmm I wonder whether they haven’t addressed other issues there this is an easy pharmaceutical trick
Dr Dave McCarty (29:49)
I’m afraid of the same sort of slippery slope is that ADHD is such a non-specific form of dysfunction, you know, because lots of flavors of that neurocognitive impairment can fit into that. And it’s so commonly overlapping with just not sleeping well. So those symptoms, the Venn diagram is pretty large.
And if we don’t address the breathing, if we don’t even look for the breathing, we won’t even find it quite frankly, the diagnosis of sleep apnea is not hard to achieve anymore. So you just need to have five non-desaturating, non-oxygen dropping obstructive events per hour, plus some sort of complaint about the sleep wake experience. So it’s really not, if you really wanted to push the matter, it’s not hard to get that diagnosis onto your chart. The real question is, know, which moving parts are important to you?
And what steps should we take to try to get you closer to that tranquil, deep, continuous sleep that makes you feel restored? Usually it’s there’s a lot more in there than just apply CPAP. You’re good to go. Yes. You know, it’s a bigger puzzle than that.
Dr Ron Ehrlich (31:14)
And in fact, by approaching it as a bigger puzzle, the upsides are much greater as well. The rewards, the rewards.
Dr Dave McCarty (31:25)
I think so. think so. know, what I’ve seen and I write in all my work when I do things on social media, I’ll put hashtag empowerment saves. You know, it sounds like I’m running some sort of a, I know, a, a, a, a, a, a, a, a,
when I recognize them, when you give people the pieces of the puzzle and they suddenly see there’s the lights come on and they say, well, if this is true, what if I did this? And that you can suddenly see the wheels start turning and they get engaged in the process. And it’s a moment. And it’s a moment when they become empowered with their own kind of future and trajectory in healthcare. So I love that moment when it happens.
And the five reasons to treat curated discussion is a repetitive way to see that moment again and again. And it’s strange. It’s something as a clinician, it’s a little shot of dopamine because you feel that that person sitting across from you, they finally get it and they can finally sort of start navigating this on their own steam a little bit. Does that make any sense? Have you seen that moment come on in a patient’s
Dr Ron Ehrlich (32:51)
Yes, absolutely. And I mean, I think this is the beauty of personally empowering patients to take control of many aspects of their health rather than take a more fatalistic, well, it’s genetic. It’s my family or because the doctor does all, all this is not uncommon either Dave, the doctor, because they don’t know what to do. Say there is nothing that you can do. It’s genetic.
You know, if I don’t know it, if I don’t know it, it’s not worth knowing. Just go off and put your affairs in order. But that, that kind of segues into the next question. And I love the way Dave, that you’ve always come back to these five. I’ve done the same with my five stressors and five pillars. There must be something about our five fingers, but if the five-fingered approach was born from a patient encounter, you had, think the woman’s name was Daria. Can you tell us that story and what the framework actually does?
Dr Dave McCarty (33:48)
It’s a fictionalized name, but the story was true. This is told in the Empowered Sleep Apnea Project. But the idea was that this was a patient that I saw for the first time as a new attending. So I was a new attending in sleep, which means that I was kind of helping other trainees learn the ropes of sleep medicine. And I open up this chart for this young woman who has this diagnosis called sleep apnea.
And at the time, this was still relatively new. I felt like a hotshot because I kind of knew what apnea was. But I’m opening this chart and looking through the progress notes. And each one was pretty much like the last. It said, you know, they were soap notes, subjective, you know, patient presents, per follow up of sleep apnea, no complaints, objective, vital signs stable, no dermal irritation, know, assessment, doing well on CPAP plan, follow up one year. You know, it all sounded… kind of like, wow, easy, easy.
There’s like five notes like this. So I figured this was probably going to be a fairly simple visit when I walked in. And when I met this woman, it was clearly not straightforward. She was, you know, had this device in her lap, but really wasn’t looking very engaged. And when I started pressing her on this, I couldn’t figure out what this machine was doing for her. And neither could she.
and she remained excessively sleepy. She really didn’t feel like it was doing much of it. So bottom line was we went and retested her and she had lost some weight since her original label or diagnosis had been given. Her repeat apnea hypopnea index was sort of sub threshold for diagnosis even.
And when we actually sort of pursued this, the reason for her symptoms was that she had type one narcolepsy. And so I was left kind of wondering how could we have done this? You know, who made this mistake? And there was no mistake because they diagnosed sleep apnea, they treated sleep apnea and everything was right, but it was so wrong. And when she said, no,
Dr Ron Ehrlich (35:56)
the
Dr Dave McCarty (36:01)
Narcolepsy is a different type of neurologic disorder that causes people to feel sleepy in the daytime. So the problem was we were fooled from the beginning because she said, I’m sleepy and someone asked me a snore and she might’ve said, yes, once. And then someone said, I know what that is. I know what that is. That’s we have a thing for that. That’s called sleep out. And so there’s this desire to diagnose stuff that you know how to treat.
And once you get there,
there’s this very human need to kind of care for that thing that you’ve diagnosed. That’s the thing you’re working on. And so it takes on a life of its own. So the problem here was somewhere along the line, we lost track of this woman’s narrative. We lost track of her story and we started caring for her label. And so I got obsessed after that moment with why doctors can make mistakes. Why do diagnostic mistakes happen?
And I started reading about this and I determined that I didn’t want this to happen in my training program again. So the type of mistake that happened with Daria’s case was a case called early closure of decision-making. They call it a search satisfying error. Satisfying is a blended word like smog is a blended word, but it means that it’s satisfactory and sufficient. It makes sense.
And so when you get there, you take a mental nap and you stop problem solving because you feel like you’ve arrived. It’s a way for the human brain to deal with terrible complexity. And so a way to protect yourself against that is to have a way of mapping back to the patient’s story so that you can’t forget what you’re working on. So this is what the five finger approach really is, is you start with the patient’s narrative.
What’s wrong with you? What do you feel is wrong? And then you take it to the hand. And so you can just investigate. Again, this is a co-discovery kind of process, but you walk with the patient through several different domains. And the thumb of the five finger approach is circadian misalignment. And that’s a jargony mouthful. That just means that your days and nights are kind of mixed up. Think the last time you got jet lag, how hard it was to go to sleep or how hard it was to wake up. People can do that to themselves based on when they’re experiencing light exposure and stuff. So it’s hard to talk about. Circadian rhythm involves the notion of circular time and teaching about it can be a little bit difficult. So in the Empowered Sleep Apnea Project for your listeners, we try and make everything a little bit more fun.
There’s a toy called the Circadian Rhythmo Wheel that you can download from the site and you can print it out and just as you kind of spin this thing around so you can see where these circadian events happen and you can start getting your head wrapped around why having your circadian rhythm out of whack can contribute to things like insomnia. So that’s the thumb circadian misalignment.
The others are something that you just kind of walk through and ask yourself, could it be this? So the index finger is pharmacologic factors. These are all the things we take, drink, smoke, eat, apply, all of the stuff that might be pharmacologically active. Take a critical look at it. Could the reason for this person’s narrative be coming from one of these things? Okay, it’s an important step.
And this came from the recognition that I would see of young people coming in for a terrible complaint of insomnia and you review their their medication lists and somewhere along the line they’ve been given several very very potent cns stimulating agents for other diagnoses you know anxiety or something venlafaxine is a pretty potent cns stimulating agent as you mentioned amphetamines given for adhd can be really stimulating so if you don’t take a look at them at the meds, you can really do the person a disservice and blame everything on something else.
Like sleep apnea. The middle finger medical factors, medical factors. So this is just the notion that if I come to the doctor and I say, Hey, I don’t feel good. ⁓ If all I’m looking for is sleep apnea, that’s all I’m going to treat. And I might sort of miss a lot of other things that can make you feel lousy.
So let’s just take a common for example. In the modern age, a lot of people don’t get outside as much as they should and they’re working in a little cubicle. It’s not uncommon for an adult to have real critical vitamin D deficiency. That’s a real thing. And that makes you feel lousy in lots of different ways. And if it’s not discovered, you might miss an opportunity to help this person heal.
So medical factors think about the medical problems that could be causing this array of symptoms. Ring finger in the five finger approach is psychiatric and psychosocial factors. This is based on the, I’d call it a common sense understanding of sleep wake experience. If we don’t explore that through the lens of mental health and personal safety, we’re missing another way to kind of think about this. So it’s a stopping point.
Are you safe at home? PTSD physiology, post-traumatic stress disorder physiology, isn’t just for combat vets anymore. A lot of people are living with kind of physiology of stress and that’s part of their sleep-wake disturbance. So understanding that that is there is the first step. And as we visit these, we actually visit the five-finger approach in clinic with our patients as a system.
So that they can kind of see what we’re working on and they can sort of weigh in. yeah, yeah, I think that is something I’d like to talk about because cognitive behavioral therapy for insomnia isn’t just for specialists anymore. These are techniques that we need to be talking about as clinicians in a much larger sense and the tools are something we all can learn about. So that’s the ring finger. Pinky finger of the five finger approach is so-called primary sleep diagnoses. I put that very last to prevent the mistake like Darius from happening so that folks would do the full review.
And if we get to sleep apnea, we would also recognize that, hey, there’s other things in that finger too. And so if the person’s not getting better, we can revisit this. This is an iterative process. So, hey, Ron, you’re back. How’s your narrative? you’re still sleepy? Hmm. We’ve got your sleep apnea under control. I wonder which finger we should be looking at and we can kind of revisit it.
I find that I love teaching this to my patients because especially the ones who kind of they like to know where the gears are on their car and they like to know where the oil is. So they people understand this schema. And if someone comes back and they say, well, I’m not doing so well, I say, well, I when I want to talk about it, they say, I know what it is. I’ve been I’ve been watching TV too late. My circadian rhythms really drifted.
So I know what I’m supposed to do, Doc. You don’t need to lecture me. but but you see, the point is they feel like they’ve got their hand wrapped around it and it gives people a sense of ownership and a way to investigate something that can be a very, very messy topic.
Dr Ron Ehrlich (43:26)
Well, this is the empowered story coming back. The, the, mean, you’ve mentioned it a couple of times. You’re, you’re a very prolific writer, Dave. And I love reading your blog posts, which, you know, we’ll have links to on, on from your website, Dave’s notes. think, but, but you, wrote about, and you’ve said it a couple of times here, but I want to bring it out a bit more. This narrative based medicine that it’s, you know, you could even say it might save us all.
You kind of think to yourself, well, okay, what, not only what is it, but what are, what are we, what’s the alternative to it that people are probably a lot more familiar with and think, isn’t this the way medicine is done? And what is this thing called narrative based medicine? Give us the, what it is now, most often that people are exposed to and what you’ve described as narrative based medicine.
Dr Dave McCarty (44:21)
Well, I’m trying to start a conversation about the goal of what we’re trying to achieve with the visit. What sleep medicine has been reduced to in the name of efficiency and access is a very efficient mechanism to get someone labeled, diagnosed, and have access on effective treatment, which is usually a CPAP machine or maybe a mandibular advancement device. So it’s very efficient.
And it makes a lot of sense when you view it from that lens. But when we view sleep apnea from the other side, back to the beginning of our conversation, that it’s not one thing, that it’s this very complex set of things that have many moving parts. And we get the idea that there has to be a little bit more patient involvement in terms of which moving part we’re going to work on now and why. So this comes down to the patient’s story.
We have to then step away from the label as a basis for making decisions and recommendations. And we go back to the story. And this is where it gets really messy. Because we’ve all kind of learned as medical trainees how bad it is to interrupt your patient. There’s a lecture about doctors interrupt their patient on average after about 30 seconds. They show you the video. I don’t know if they’re still doing that.
But there’s this big study that came out. internalistic flavor of medicine is not necessarily a good thing. So we’re told about empathy and we’re told about the things that one does like leaning in and the body language. It’s all part of the curriculum, right? So yet dot dot dot. If you let the patient walk in the room and simply tell you their story, there is no end to that because they have lots of ideas about what it could be.
They may or may not be right. And so this becomes in very short order a very large hot mess. And so what do you do with that? You revert to the label and you end up with a problem like Darya’s again, because it’s too scary to deal with that hot mess. So ⁓ I’m talking about the process of label-based medicine versus narrative-based medicine, because the alternative to the label, which is the hot mess, has to have some structure. And this is where
The five finger approach comes in as a nice shareable structure and the five reasons to treat is a nice complexity structure that we can say, you know, this is a, this is a big problem. Let’s how, can we share the way we can talk about this between clinician and patient so that everyone’s on the same page and the patient ultimately is the one who makes the decision rather than someone telling that patient what to do.
So narrative based medicine is complex complexity requires some sort of structure and in the sleep medicine environment, the two five-point mnemonics that we’re just talking about, five-point complexity deconstruction tools, which is the five-finger approach and the five reasons to treat, these work well. Because I think it boils down to if we’re going to share a complex journey, we need to prepare the patient with language that allows them to work with people in different silos of thought the language of sleep apnea has diverged.
Some people use upper airway resistance syndrome now. Some people call it breathing disordered sleep. Some people still say, no, it has to be called sleep apnea. So we’ve got language that’s spreading out. And if the patient gets caught in the middle of those little language wars, it doesn’t do them any good. So I think that in order for us to play nicely together, we have to share collectively the answers to three fundamental questions, right? Three fundamental questions. Question one, what is sleep apnea?
And we started this program with my answer to that. It’s sleep apnea is a jargon word that means unstable breathing during sleep that has two different flavors, each of which has many moving parts. So what is sleep apnea? How we talk about that is really crucial. And if you ask a lot of, know, ask around just socially, ask people, know, tell me what sleep apnea is.
They’ll tell you different answers and they’ll all be right, but they might not prepare the person to have a journey in a different silo other than theirs. So that’s question one. What is sleep apnea? Second question is, what else could this be? That’s our stopping point so we don’t make the mistake for daria. And we actually think about the five finger approach. And then the third question is, why should we treat it?
Why should we stabilize it? And the answer to that comes with the five reasons to treat discussion. narrative-based medicine, hard, complicated, complex, hot mess. If you don’t have structure, adding structure allows us to navigate through it, but we have to be able to share that structure with our patients to allow them to participate in the conversations. That’s narrative-based medicine to me.
Dr Ron Ehrlich (49:39)
I love it. And, and I’m reminded of a, a mentor of mine who has influenced my practice for over 30, 35 years. She was 92 when I did her program. used to be president Kennedy and president Johnson’s doctor in the white house. Wow. And Janet Trevelle is her name. And she said, if you ask your patients the right questions, they’ll often not only tell you what’s wrong with them, but they’ll tell you how to fix it.
And I think your five-fingered approach and five reasons to treat provides a very good structure to listen to that narrative. And when you think about how we as health practitioners learnt, very didactic, you sit in a lecture hall and listen and write notes. We take that into our, our, our clinics and we are didactically dictating to our patients what they should do. We really should be facilitating a conversation.
And your structure provides a great way to do it. love it, Dave. This is why I get you back. I also need, I also need updates on this and I’m sure my patients do too. Listen, you are, as I said, you’re so prolific. You’re right. You draw beautifully. So many of your, all your artwork is great. I’d rate, we’re to have links to your website and books, but I’m really interested in what is inspiring you most in 2026 and what is the message that you most want people to walk away with?
Dr Dave McCarty (51:06)
No question. It’s about the nose. So the latest book in the Empowered Sleep Apnea project is called The Nose Rules. Empowered Sleep Apnea presents the Nose Rules. And the basic idea is nasal breathing is different. And I now consider myself to be a nasocentric breathing sleep physician, if that makes any sense. We now have a new and different emerging tools to assess not just nasal structure, but nasal function. So a brand new tool, and this is actually the unveiling of this is coming very soon to our clinical ecosystem. It’s called nasal rhino manometry. ever heard of that?
Dr Ron Ehrlich (51:55)
No, but if we break it down, nasal, rhino, go on, Rhino, go on, break that down.
Dr Dave McCarty (52:01)
Yes.
Rhino manometry. So that means we’re actually measuring pressures and flow through the nose. So, know, clinically I can say, well, I have some difficulty breathing through my nose, but it’s hard to quantify that. We have ways of quantifying breathing with something called pulmonary function testing. That’s for asthma and emphysema and those types of disorders, but no real standard clinical tool in sleep medicine to assess nasal breathing. And if we accept that the nose is important and nasal breathing is important, and it might predict who’s gonna do well with CPAP versus who might need something done first, then this is an important part of our treatment planning. So if you ask me what’s the most important message for 2026, it’s about awareness for the importance of nasal breathing, that this is physiologically different. Nasal breathing allows us better bioavailability of oxygen.
If that makes any sense. So there is this phenomenon of the paranasal sinuses, illicit a substance called nitric oxide. And as we breathe, that nitric oxide mixes with the air. And those people who follow medicine got interested in nitric oxide because that’s the molecule that affects blood flow. And for Viagra, it was the molecule of interest. So nitric oxide affects blood flow. And when we breathe in through our nose, it allows for better alveolar filling of alveolar blood flow. So it allows better bioavailability of the oxygen that we breathe.
What? That’s incredible. But not only that, nasal breathing while we are developing, as opposed to mouth breathing as we’re growing, can make our faces a different shape. Think about that for a minute. Because where is the tongue when we’re nasal breathing?
The tongue is up there at the roof of the mouth. And if the mouth is open, well, the roof of the mouth might just end up shaped like that, which means that the nose is correspondingly collapsed. So if I could spread one big message worldwide, it’s not just about the sleep, it’s not just about the breathing, it’s about helping us reestablish functional, effortless nasodiaphrasmatic breathing 24-7 day and night.
Dr Ron Ehrlich (54:26)
Well, this is, this is music to our ears. Cause you know, breathing is a very, it’s a major pillar of what we’ve focused on in this program as well. And interestingly, I remember talking to Dr. Resul, but Courtney who’s done a PhD. She’s an osteopath with 40, 50 years of experience who after 20 years decided, yes, after 20 years of osteopathy decided that the best way she could help her patients was to do a PhD in breathing.
And, that’s what she did. And she once said to me, 60 % of the body’s nitric oxide is produced in the paranasal sinuses only when you breathe through your nose. And I thought, wow, not only is a vasodilator, but also as an antimicrobial powerful. But then I did another podcast with somebody just on nitric oxide who said, unless the oral mic, the only way that happens, Ron.
I was telling him this and I was very proud of myself. And he said, the only way this happens Ron is if the enzymes in the oral cavity will facilitate that. And if the oral microbiome is out of balance, that isn’t true. I thought, well, yes, I know.
Dr Dave McCarty (55:39)
Yeah, the oral microbiome is another rabbit hole of fascinating discovery.
Dr Ron Ehrlich (55:46)
It is, is. Dave, I want to thank you. love getting you back on for all the reasons I’ve already said. And I want to thank you for all the wonderful work you are doing and the energy you are bringing to this very complex field. And thank you so much for joining us today and sharing your knowledge and wisdom with us.
Dr Dave McCarty (56:06)
Ron, it’s been a pleasure. Thank you so much.
Dr Ron Ehrlich (56:08)
Well, as I said, if it, a practitioner, this narrative based approach, which is what my mentor of over 35 years ago, inspired me for, but what I love about Dave is not only his empowered focus, but the structure to have that narrative with a patient, the five reasons to treat what is your risk? Do you snore? How do you sleep? What do you like when you’re awake? And what are some of the comorbidities? What about the five-fingered approach circadian harmony. mean, my goodness, there’s a whole subject on its own.
Our relationship with sun, particularly early morning sun and the radiation, which we bathe ourselves in constantly and the blue lights that we also bathe ourselves. Pharma, the pharmacological interactions. And when you think about not just the medications people are on, but a whole lot more medical factors, psychosocial, issues and of course finally interestingly for a discussion on sleep the actual diagnosis itself look we’ll have links to Dave’s site Empowered
Sleep Apnea I’d encourage you to follow him and his notes or his essays that he writes they are so interesting and stimulating and inspiring and I would also encourage you to join our unstressed health community until next time this is Dr Ron Erlich
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