The New Idea

By David E McCarty MD, FAASM (but you can call me DAVE)

In the world of SLEEP, if there’s one specialty that gets it, it’s myofunctional therapy.

Oh, but as usual, I’m getting ahead of myself.

 I just returned from Phoenix, where I attended Collaboration Cures, a joint meeting of the American Academy of Physiologic Medicine and Dentistry and the American Academy for Oral Systemic Health. Both of these groups were founded within the Dental community, in an effort to promote more cross-pollination of ideas, within the complex world of airway-related health, with an explicit goal of getting people to actually talk to each other and collaborate.

I’ll simply say that I found it to be a most…refreshing environment.

See, one of the most exciting developments in the field of Sleep Medicine in the last decade has been the emergence of a new discipline within dentistry called Airway-Centered Dentistry. This is more than just a poster on the wall at your Dentist’s office, with the possibility of fitting you with a mandibular advancement device to treat Sleep Apnea in-between cleanings.

Airway Centered Dentistry is bigger than that.

Airway Centered Dentistry recognizes that Sleep Apnea is more than just floppy tissues in the back of the throat…Sleep Apnea is a vastly complex combination of problems, that has evolved since it was first described.

Which perhaps requires yet another digression.

Cue harp glissando as time travels backward…

In 1836, a young Charles Dickens wrote a newspaper serial that would later be published as his first novel, with the now-famous-but-still-clunky title of The Posthumous Papers of the Pickwick Club, now shortened by pretty much everybody to The Pickwick Papers.

See, it was Dickens who first noted the phenotype that would later become the legend. In the story, there’s a character called Fat Joe, an unfortunate soul who snores when he’s awake and falls asleep on his feet, the intended effect being comedy.

Fat Joe: The original phenotype

Partway into the 20th century, though, the medical world wasn’t laughing. By mid-century, doctors had sniffed the signal that guys like Fat Joe had more medical problems, like heart failure and pulmonary hypertension. They coined a name for the phenotype.

They called it Pickwickian Syndrome.

In 1966, Henri Gastaut and his team decided to use a new technique called Polysomnography to study the Pickwickian Syndrome. What his team found in all of these obese, sleepy snorers was that their sleep was heavily fragmented by severe periodic limitations in breathing. Most of those limitations were obstructive, though central apneas were seen, too.

Sleep Apnea, nice to make your acquaintance!

Place your mind into that space, back then, in 1966. These individuals, each a walking, talking version of our fictional friend Fat Joe…these people now had a possible explanation for their devastating daytime limitations, but there is also a stupidly obvious solution:

Help them breathe, and you’ll help them get better!

The breathing limitations noted by Gastaut…the next step was to quantify them. Capture them. Study them. Give them names. See what they do. Henceforth, we see much lively discussion in the scientific literature about how these terms are defined. Central vs Obstructive. Apnea vs Hypopnea. RERAs vs UARS.

The debate as to the “best” way to define these events continues to this day.

The reason I’m blowing so much hot air about the semantics of bean-counting is to call attention to this seemingly small, but actually seismically important fact:

The diagnosis of Sleep Apnea can now be made merely by reaching a specific threshold number of events on a sleep study.

(Pickwickian phenotype no longer needed.)

I submit that this small truth has rocked the world of Sleep Medicine into an existential crisis, and the party’s only getting started.

The last century has shown us literally a changing face of the human race. Our jawbones are smaller than they were a hundred years ago. Our faces are narrower. Our nasal airspaces are more collapsed, harder to breathe through.

Fat Joe is still part of the landscape, Life-Fans, don’t get me wrong. The Pickwickian phenotype has not gone away.  Obese, snoring sleepy people are still out there, and they are still most likely to benefit from using a PAP machine. It’s the most effective therapy we have.

It’s just that, these days, Fat Joe is getting outnumbered by a different phenotype. Thin Lizzy, perhaps? Slender folks, with overdriven sympathetic nervous systems. Nasally-congested, insomniac, brain-fogged, hypertensive, bruxing migraineurs, who seem to have an instinctive aversion to having a CPAP mask on their face.

“Thin Lizzy”: The changing face of Sleep Apnea.

These are the ones who get left behind by a system that seems to continue to insist that their problem is a simple case of PAP-deficiency.

The actual percentage who balk treatment before entering the gate is unknown, but everyone agrees that it’s high. Life-Fans, this is no time to be going it alone, pretending like you’ve got all the answers worked out.

Which brings me back to my original point, dear readers, which is this one:

In the world of SLEEP, if there’s one specialty that gets it, it’s myofunctional therapy. Weak muscles can be retrained. Stiff, restricted muscles can be loosened, made more mobile. Clogged nasal airspaces can be made patent. Maladaptive breathing can be coached.

Myofunctional therapists are perhaps the most collaborative of all of us because they know that their success is so deeply intertwined with other disciplines, including those strategies considered “traditional” (like PAP therapy and oral appliance therapy).

“Myos” witness first-hand how the addition of successful nasal breathing strategies can make all the difference. They know that, sometimes, the “box” of the craniofacial respiratory complex is simply too small, and that more room might be necessary for their manipulations to work.  They know when to ask for help, and when they need to be allowed to do their jobs.

By my observation, this isn’t book knowledge to them. It’s simply a natural Myo-instinct that all successful journeys are going to require teamwork.

See, Myos are used to the complexity of Sleep Apnea, an aspect that I often call The Lovecraftian Nightmare. They know Sleep Apnea is not just ONE THING.

Sleep Apnea.

We’re gonna need a bigger fleet.

Sure, Myos understand the mechanical aspects of breathing; Of course, they’ve studied the chemical drives for breathing—no doubt! But they’ve also mastered the much more subtle craft of inspiring their patients. Of getting beyond the breathing and getting into their patient’s hearts. And I believe it’s because they themselves see and understand the complexity of the situation. They know about the Lovecraftian Nightmare.

I suspect it’s because of this awareness of the whole that they can so effectively coach their patients about where they are, where they might go, and what they might expect.

This collaborative, integrative spirit is truly in keeping with the foundations of Patient-Centered Medicine. It’s care like this that gives patients agency. Empowerment.

I submit today that all providers would be wise to model themselves thusly. As the rising push towards automated home sleep testing reaches its potential (which will be soon, mark me) the label of Sleep Apnea will be slapped onto the foreheads of tens of millions of Americans, many of them going in with no real clue as to how they got there, or where they should go for effective coaching, to try to help them unify the fragmented flotsam and jetsam of our healthcare delivery system.

Kind of like being washed up on an island, with no map.

It troubles me that in 2022, the major academic organizations for SLEEP—for Medicine it’s the American Academy of Sleep Medicine and for Dentistry, it’s the American Academy of Dental Sleep Medicine—don’t even coordinate their meetings anymore. If mutual benefit requires an instinctively collaborative mindset, this is heading in the wrong direction.

Perhaps the Myos have something other than physiotherapy techniques to teach us.

One of the comments that most warmed my heart whilst I was in Pheonix was made by a young myofunctional therapist named Abby, as she was leafing through the glossy pages of Empowered Sleep Apnea, smiling at the cartoons, exclaiming about the layout, the easy style, the zany fonts.

“It’s just so…it’s just so FUN,” she giggled. That was nice, but that wasn’t the important part. The important part was this: she told me that, in her job, this is the hardest part they face while they are teaching. Taking difficult, scary, complex material—aka The Lovecraftian Nightmare—and making it FUN.

And it occurred to me, right then, that she summed it all up, very simply, nicely, beautifully.

 The Mojo of the Empowered Sleep Apnea project, in its entirety, can be captured in the following seven words:

If it’s not FUN, it’s no fun!

At that moment, I decided to adopt it, as our official-not-official mission statement of sorts, which generally means that there’s a cartoon brewing, which, of course, there was.

As you might have guessed, all of the above logorrhea simply serves as a prelude to my cartoon-thoughts for the day, a brazen brain-slap I’ve been chewing on for quite some time, until it finally begged to be written down because I met a lovely young myofunctional therapist with a big heart named Abby who made it so clear why it was all so important.

Is that a new idea?

The New Idea

Post-Script:

If it’s not FUN,

it’s no fun

Recommended Reading:

Bardes, CL. Defining Patient Centered Medicine. NEJM. 366;9: 782-3 (2012). (N.B.: The term Patient-Centered Medicine gets thrown around quite a bit these days. It doesn’t mean that you get to go to an office with an iPad for a checkin system. That’s not Patient-Centered Medicine. You wanna know what patient centered medicine smells like? Read this beauty of an OpEd in NEJM. It’s a decade old, but it’s worthy).

Gastaut H, Tassinari C, Duron B. Polygraphic study of the episodic diurnal and nocturnal (hypnic and respiratory) manifestations of the Pickwick Syndrome. Brain Research 12 (1966): 167-86

Redline S, Sanders M. Hypopnea, a floating metric: implications for prevalence, morbidity estimates, and case finding. Sleep. 1997 Dec;20(12):1209-17. (N.B.: Prof Redline is a luminary in the field of Sleep Apnea research.She noted the difficulties we would have with our definition of hypopnea early in the journey. She was right.)