The main advantage to home testing is it's way simpler. A lot of people won't do testing. The reason why a lot of people do not get diagnosed is because they're told to do a sleep test, and they think the only way to do this is to go into a lab stay overnight. They don't want to do it. And that's not the case. 90% of people today can be treated and tested at home. One of the other advantages is you're testing in your own bed in a real environment where you're gonna sleep every day. In that regard, it can be more accurate.

In our last episode, we talked about how patients get evaluated for sleep apnea. Today we're going deeper. There are many different types of sleep tests and airway evaluations, from home sleep studies to full overnight lab testing to advanced imaging of the airway. Each one provides different pieces of the puzzle. So today, Dr. Eck helps us understand what these tests actually measure, what they miss, and how they work together to guide treatment decisions. Hi, Dr. Eck.

How are you doing today?

Good. Thank you. It's nice to see you. Um like I said, we spoke about a little bit about this last episode, but let's go deeper. Uh let's start with home sleep tests. How do they work and what kinds of information do they typically collect?

There's there's lots of different types of home sleep tests uh available on the market. And they are not all equal. Uh there are level one, level two, level three tests, level three being the most accurate. But with that said, not even all level three tests are created equal. For an at-home test, you want to be sure that it gives you all the information necessary and does not leave certain things out. What it needs to give you is hypotenias, which means you have a resistance of at least 30% in breathing. It needs to give you apneas, which means there is a 100% cessation of breathing. Central apneas. It should give you your minimum oxygen levels and amount of time that you spend with your oxygen below 90%, should give you your maximum heart rate, and it should give you the amount of time you spend snoring. Your stages of sleep, as we've discussed previously, are very important. RIM and deep sleep. It should give you those. It should give you rears, and it should give you and break out your AHI. So your AHI, remember, is your amount of times that you have an apnea event and a hypotony event divided by the amount of time that you slept. It should also break this out into what's called AHI RIM, which is how many of these events do you have not just overall through the night, but during your RIM sleep. And we'll get into details down the road in a future episode about the importance of this, but it should be broken out. We want to also test and give us events by position, because there are times when people will be worse in one position or the other. So it should tell us your back, your left, your right, your stomach, and it should break those out. Many tests leave some of these out. A lot of tests leave snoring out or the positions out. And to me, the number one chief complaint that a lot of patients have is the snoring. Well, how do you know if you're improving if you don't test it, know where you're at, and where you're going? If your chief concern is snoring, but they don't test for it, then you can't tell whether you're improving or not. And if our chief concern is shortness of breath, then you know, how much are we out of breath? So we should be able to test all of these things. And some of them do leave some of these things out.

And what are the advantages of home testing and where do they fall short?

The main advantage to home testing is one, it's way simpler, way easier. A lot of people won't do testing. The reason why a lot of people do not get diagnosed is because they're told to do a sleep test and they think the only way to do this is to go into a lab stay overnight. They don't want to do it. And that's not the case. 90% of people today can be treated and tested at home. One of the other advantages is you're testing in your own bed in a real environment where you're gonna sleep every day. And so, in that regard, it can be more accurate because that's what you're gonna go through every day, right? If you sleep naked, you sleep on your side or your stomach, and you go to an in-lab uh test, well, you're not gonna be able to do that. You're gonna pretty much be on your back. And uh we can't we can't sleep the way we normally would at home. So there are some advantages to doing it in the lab. The other big advantage that we have is we can do multiple nights. We can do two, three, or four nights. Whereas, and sometimes from one night to the next, we can have variable sleep. So this allows us to average and see what's going on. Whereas if you go to an in-lab, it's a one-night shot. So whatever it is that night, it is, there is no two nights, okay, or three nights to average together. The main area where at-home sleep testing falls short is if we're expecting certain problems, certain neurological issues, or let's say cardiovascular issues, well, you can pick those up sometimes on an in-lab test because you have an EKG and you have these leads on you, uh, and you can help to pick up some of these other medical conditions.

Okay, so I s I I I hear a lot more advantages than these disadvantages. It would be a first um good way to test, right? And if something needs deeper assessment, then you can do in lab, but that would it work that way as well, or yeah.

So the most for the most part, you start with at home. There are certain neurological issues, conditions, and things you would look at to say, okay, this would be better with an in-lab, but that's not the majority of people. Majority of people you start with an at-home. And then you only go to an in-lab if if something is uh amiss or you detect certain things.

And are there patients whose sleep apnea might be missed or underestimated with a home test?

Well, as a general rule, uh, everybody's sleep test is underestimating what's going on. So keep in mind, in order to count on a sleep test, as a hypotnia or an apnea, to create this AHI index, you have to stop breathing for at least 10 seconds, and your oxygen has to drop by at least 4%. Well, if you have to stop breathing for 10 seconds to count, what happens for every time you stop breathing for 9.5 seconds or 9 seconds or 8 seconds? All of these tests do not pick those up. So keep in mind all tests are really underestimating what's going on. The main thing is that AHI scale that everybody uses, it was never intended to use to be used for clinical use and clinical purposes. It was designed for research and statistics. And it's what everybody seems to use because that is what the insurance companies use. And so for that reason, a lot of things on a sleep test are missed, not because the sleep tests don't pick it up, but because everybody ignores everything else. I always tell patients the least important number on a sleep test probably is the number of times you stop breathing. What's important is what's going on with your heart rate, your oxygen levels, your stages of sleep. Because that tells us the impact it's really having on the body.

So that's something you look at uh personally, Dr. Egg? Like when you mentioned that sleep uh at-home sleep tests also underestimate um how well your sleep is, right? If I'm not mistaken, you mentioned a number, like if it's if you stop breathing for nine and a half seconds, do you look that's already bad because it's like close to ten. Do you look at that?

Even if tests don't market us We can't look at it because it's not on the data. All the tests are set to just report those that are 10 seconds or longer. That's why we can take somebody who has all of these symptoms and don't seem to have enough results on the test to meet up with those symptoms. Well that what that tells you is they're getting a lot of those shorter time periods probably that do not show up.

Okay, so you would uh treat those people or suggest treatment for those people as well.

Yes, because one, you have to pay attention to symptoms, and this is why paying attention to the other numbers, not just the amount of time that we stop breathing, is important. If you take somebody whose AHI is very mild, it's under a five, it does not reach the level of being sleep apnea, but they have all these symptoms. But now you look at their sleep test, and their oxygen is down, their stages of sleep are very low, well that tells you they're having events, they're having issues. They just don't reach the level of an apnea event, meaning it doesn't last 10 seconds.

And and how is uh an in-lab sleep study different from a home test in terms of what's measured?

Well, the main thing is you you get brain activity, uh, you get an EEG, leads that are put on, you get eye movements that are measured, uh EOG, you get muscle activity, which can detect things like bruxism or grinding, restless leg syndrome, uh, and you also get a video. They actually are video recording you sleeping. So if you have harisomnia activities, sleepwalking, sleep eating, things like that, then they can monitor that.

And what additional insights can doctors gain when they monitor brainwaves uh sleep stages and body movements overnight?

And keeping in mind that stages of sleep, there are level sleep tests that do measure stages of sleep. And uh both tests that I use on a regular basis all test body position. They all test snoring and they all test stages of sleep. Because for me, these are vital. Um the stages of sleep are very important. We've discussed this in the past. Uh this is one way an at-home test can be good, but then can be bad if they do not test these. So you want to make sure that you're testing for these. We had an episode on the stages of sleep already, right, where we talk about RIM and deep sleep and how important they are. Um you cannot get that one number I mentioned, the AHI RIM, you cannot get that number if you're not measuring stages of sleep. So you want to make sure, I mean, all in labs measure stages of sleep, not all at home tests measure stages of sleep.

But it's something that you test for in your practice. Like if you uh recommend a sleep test, would it be one that that measures uh stages of sleep?

Yes, always.

When do you feel an in lab study is especially important? You mentioned certain neurological problems.

There's several indications for doing an in lab, uh certain medical interviews as we talked about, but when the at-home sleep test is inconclusive or does not match your symptoms, then that sometimes can be an indication to do an in lab test. As I mentioned, suspected cardiovascular disease, or the patient has not otherwise had any tests done for that, then that can be picked up in an in lab sleep test. When they choose CPAP as an option and they're not responding to it, then the titration study can be done, which is an in-lab test, where somebody's there to monitor you and manually adjust the CPAP up and down. There's a lot of people who get CPAPs now that are done through telemedicine. So they take a test or an at-home test, and then somebody ships them a CPAP, and then they tell them to do it within these certain um pressures, and then they do an at-home seat test, and the CPAP isn't working for them. Those people should have an in-lab test so it can be titrated possible as good as possible for them.

And as a dentist specializing in airway treatment, you often use 3D imaging like C B C T scans. What do these scans reveal about the airway?

The sleep test tells us what's going on. The 3D images tells us why it's going on. If we're going to treat with a mask, okay, the why kind of doesn't matter because everybody's going to get the same thing. They're getting a mask. But the moment a patient is looking for an alternative outside of the mask, then we have to know the why to know what options will work to treat them. It shows us the restrictions in the airways. It shows us the sinuses. It can tell us the cause of the obstructions. I always use the kink in the hose analogy, which we talked about before, right? If you have kink in the hose, and you gotta go find the kink in the hose to relieve it, right? You gotta know where the kink in the airway is to know how to relieve it.

And so so so it's something that you always uh test for before you're setting up a treatment for someone. Like after you know what's going on, you always look into why it is happening so that you can personalize that treatment specifically for that person.

Yes, we don't we don't give anybody a treatment plan without a 3D image first. So we to take the sleep study and then we take the 3D image and combine the two uh in order to determine what treatment options will work. Everybody always has more than one option that will work for them, but there's a lot of options that will not work for certain people based on these 3D images.

Okay, so it's highly personalized. There's no one size fits all.

No. There's when it comes to appliances, there's over 200 of them on the market. I mean, we personally in my offices have more than 15 different appliances that we use. We do a lot of epigenetics, we do laser treatments, we do a lot of different things, and not there's no one size fits all.

And how does evaluating jaw position palate width and tongue space help explain why sleep apnea is happening?

Well, it can be the root cause of it, and so that's important to figure out. A shorter, underdeveloped jaw leaves less room for the tongue. A narrow upper jaw and palate does two things. It leaves less room for the tongue, but that's also important because remember your hard palate, the bone in the roof of your mouth, that is the same bone as the floor of the nose. So if you have a narrow palate, you're going to have narrowing and restrictions in your nasal passage. They are the same bone. So if you can, through epigenetics, widen the palate, you can non-surgically improve the nasal passage. So it's important to know if your measurements and your jaws are within normal ranges or if they're short or narrow.

Okay, so an airway restriction can really be a result of the form of your face. Or not of your face, but of your structure. It's a structure. It's not inflammation, it's how the bone developed.

Correct. It's how it's it's the physical shape and size of your jaw bones. A short lower jaw keeps your tongue back. A narrow upper palate or a vaulted palate doesn't allow your tongue to rest up and against the palate. That also restricts the nasal passage. So they're all it's all connected.

Oh, so it's if you don't have space for your tongue to sit where it should, then the tongue can be the culprit for restricting airway. Like it's sitting in in a place where it shouldn't, so it's obstructing the airway passage.

Yeah, the tongue, yes, the tongue itself can be one of the big obstructions. And it's very rare that somebody actually has a tongue that's too big. It's almost always the space for the tongue grew too small. So the tongue does not sit where it's supposed to. This can also result in what we call myofunctional problems, where we we don't breathe right, we don't swallow right, our tongue does not posture in the right position. So when we talk about treatment options involving myofunctional, it is aimed at improving that.

Okay. And how do you combine sleep study results with airway imaging to create a personalized uh treatment plan?

No, as we mentioned, we use the test to tell us what is going on. And we use the images to tell us why. Once we figure out the why, we know what options can work for you and what options cannot work for you. So it cuts out a lot of the let's try this. Okay, that didn't work. Let's try that. You know, when people come and see us, they have oftentimes, especially the insomnia patients, they have tried for years. You know, I had a patient this morning, she's been suffering for 12 years, and she's done everything. I mean, she's flew around the country trying everything, and she has no relief. But nobody has done anything but take a hormone panel and take a sleep test. But nobody has done an examination of her jaws, her airway, a 3D image of her airwaves, nasal passages. Nobody's done any of that for her in the 12 years she's been seeking treatment.

And it's a really frustrating path to be on for a long time because you need sleep and and it's and to not be able to get answers and to leave everything for trial and error. And like you say, there's so many options, and to land in the one that's the right for you without that imaging to without knowing why is it happening particularly to you can be very exhausting, honestly. I'm I'm sure that because there are so many treatment options, but there are also so many reasons why people would have uh sleep disorders.

Yes, and it's and it's critical to have a critical evaluation of the sleep test. So we you know let's go to the positional component. I had a patient who had uh 140 central apneas. And a lot of doctors are telling their patients, well, the only way you can get rid of central apnea is, you know, a BIPAP machine. Well, we treat through epidendics, we treat central apneas all the time. But also there can be a positional component just like there can be to your snoring or your obstructive apneas. So this gentleman that had like almost 140, I think it was 136 central apneas, but I look at his sleep test and he had a positional component when he was on his left side, I believe it was his left side, he had 90% of his central apneas when he was on his left side. So when he got a positional pillow, which is a very simple treatment, to keep him off his left side, he went down, his centrals went down by 80% by a simple positional pillow. So you have to critically look at these sleep tests.

Wow, and then that that's a huge difference. And uh it's so close, it's so it's such an easy fix. But not knowing that it can be that simple is just crazy. And uh for those patients who feel confused after testing, what's the most important takeaway they should focus on?

Well, I would the most important takeaway for me would be to go seek out someone who is going to explain your test to you in a way you're gonna understand it and feel comfortable with it. Uh I know I have patients on a weekly basis that tell us, wow, nobody ever explained this to us. They got a sleep test, they've been treated for three years, and they don't understand their sleep tests. It is very common. And I think that is sad. Um that You gotta be able to show somebody what's going on. They need to understand their problem and the causes of their problem. So I would say the first thing is seek out someone that makes you understand it. You really want to focus on your oxygen. What is it doing? Okay, the stages of sleep. As these are the things that are causing your problems, right? They're medical conditions related to the sleep disorder. Irregardless of how many times you stop breathing. And that's the problem, one of the big problems that we have. Everybody focuses on that AHI scale, and that's all they ever tell anybody. They give them that number and say, okay, you're mild, moderate, severe, you don't have sleep apnea. And everything else on that test is ignored. And it's sad, but that is kind of the norm.

Doctor, I um we've reached the end of our episode. Uh is there anything else that you would like to add before we close off?

I would just say if you if you want to understand the sleep test better, we have a video on our website. It's a quick, easy video to watch, but you can visually see what the results of a sleep test are, and we go through what's important on there. These are the things to look at. So if somebody is confused about their sleep test, if they watch that video and they have a copy of their own sleep test, they can kind of piece it together like that and see what may have been missed or not explained to them.

Thank you so much, Dr. Eck, for clarifying such an important topic today. Understanding sleep testing isn't just about numbers, it's about uncovering the root causes of disruptive breathing. When the right tests are used together, patients gain clarity about their condition and confidence in their treatment options. If you found this episode helpful, share it with someone preparing for a sleep study. And learn more about airway focused sleep care visiting sleeptreatmentdirect.com. Better breathing, better sleep, better life.