A Clinically Proven Breath Device for Sleep, Speech, and More

Intro:

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Dr Ruscio:

Hey everyone. Today I spoke with Jenny Opalinski, who is a speech pathologist, and Gavin Guard from our clinic. And we were discussing this very interesting breath training device that can help people who want to sing better, speak louder, [and] breathe better. And especially, potentially, for how that pertains to athletic performance on the one side and on the other side of the spectrum, for those who have apnea or other sleep disordered breathing, this has been shown in a number of clinical trials to help with that.

Dr Ruscio:

So we’ll go over how this $55 device, this cheap device can help you with a myriad of things that actually can also help with swallowing. So for those of us who have a difficulty with swallowing pills or food, this can help there also. And then at the end of this episode, Gavin and I will be back one-on-one, discussing a experiment that we ran and how our kind of N of two experiment was derailed because of a reaction I had to a cognitive peptide that I thought was going to give me a heart attack. So there’s a little bit of a twist at the end. But we also discuss this experiment that we ran. And there’s a couple important concepts there in terms of, we did (and by we, Gavin was the only one who really finished this task) but a prepost WatchPAT One home sleep test, did the protocol with this breath training device, and then did a post WatchPAT One. And Gavin felt better, but his labs got worse. And so we’ll discuss how we reconcile this and how this perfectly fits within our clinical model.

Dr Ruscio:

And I guess while we’re there, just want to give a nod to the clinic, if you are in need of competent functional medicine care just want to remind you that myself, Joe Mather, Robert Abbot, Gavin Guard, Hannah Hamlin, our clinical team is really, in my opinion, kick butt. And I don’t say that lightly. As you know, my father and now sister are both working with our clinician team and my mother is working with one of our nutritionist slash health coaches. And so I’m quite proud of what we’re doing at the clinic. And I try to make sure that as we examine new information, what we’re finding is consistent with our clinical model. And if it’s not, we will update our clinical model. So all that to follow and we will now go to the conversation with Gavin and Jenny.

Dr Ruscio:

Hey, everyone, welcome back to Dr. Ruscio Radio. Hopefully today’s podcast will be a breath of fresh air—pun intended. We have a special guest, Jenny Opalinski, who will be helping us better understand this really cool inspiration, expiration (or breath) training device where you essentially breathe through resistance. It may help with athletic performance, but it’s been shown in some clinical trials to help with sleep apnea. So one more therapy that is cheap. Jenny just informed me that this device is only $55. I thought it was 75, only $55. And you essentially do this breathing protocol through this almost like a soundless flute-like device, and it can help strengthen the muscles with which you breathe of course, and has been clinically documented to reduce apnea. So what an easy cheap intervention that if you find yourself snoring, or maybe even feeling like you stop breathing or your partner kind of nudges you in the middle of the night, this would be a really easy experiment to run.

Dr Ruscio:

And gosh, you wouldn’t even really need to have a home sleep test or even an overnight sleep test to justify this, again, given the the inexpensive nature of the device. So that’s a little bit of the background that I’m here with Jenny, and also with Gavin Guard from the clinic. And I was facetiously referring to Gavin as our research ninja because he was the one who plucked this from this rapid stream of research that’s like a geyser, and this is something that we’ve been referring for use of our patients at the clinic, this device. And so here we are to talk about this device. I’ll say a hello to both of you guys. Hi Gavin. Hi Jenny.

Jenny Opalinski:

Hello. Thank you for having me.

Gavin Guard:

Yeah. Good to be here. Thanks, Michael.

Dr Ruscio:

That’s great. Having you guys both here to talk about a topic like I was saying, Jenny, before we got on the recording that I wish more and more people knew that there’s so much that can be done for apnea and breathing health outside of CPAP.

Jenny Opalinski:

Sure. I mean, sleep apnea is quite prevalent if you think about it in the United States, but also all over the world. And so giving people an option aside from CPAP, which very often people are pointed to immediately, it kind of opens up a space for people to be able to train in an alternative way and help themselves

Dr Ruscio:

Absolutely. And that’s what I love about this device. We’ve been referring for myofunctional therapy which, in my opinion [is] another great therapy, but this is going to be in some cases a little bit more expensive—or in some cases, a lot more expensive—and a little bit more time intensive. And it’s not to say one is better than the other, but it’s best if we have a tool kit with various tools that we can personalize, of course, to the individual. And you were starting into a background story about these inspiratory/expiratory training devices. Can you give us a little bit of the inception of these devices and then also how you found your way into working with these?

Jenny Opalinski:

Sure. I would love to. Respiratory muscle strength training, as I saying before, is still a relatively new approach. But as the research comes out, it keeps showing to be relevant in so many different populations. So inspiratory muscle strength training came about maybe 70 or so years ago and expiratory muscle strength training, maybe 20 or so. So it’s very, very new but if you take a look at the research, there is just a wealth of research ranging from helping people with swallowing problems to neurodegenerative diseases to spinal cord injury to sleep apnea now. And so that’s a really exciting application because I think it will hopefully help so many people.

Dr Ruscio:

So tell us a little bit about the inspiratory or the breathing in training. Because that was one of the things I was wondering, is there a time or an application for one as compared to the other? Obviously if you’re turning maybe 80 and you got a lot of candles on the coming cake to blow out, you want to train expiration. But what populations do these tend to map onto the best?

Jenny Opalinski:

So that’s a really good question. Actually Aspire Respiratory Products, who makes the EMST150 device, they also offer an adapter, which is the IA150. And if you put it right onto the EMST device, it changes it to an inspiratory trainer. And so basically what you’re doing with both of these trainers is you are exhaling or inhaling against a set pressure. Now these devices, the EMST150 and the adapter also, which works based on the EMST150, they’re pressure threshold devices.

Jenny Opalinski:

And so that is a little bit different from other devices you may find that are also used in respiratory muscle strength training. The reason these are different is because they are calibrated, first of all, and they are not airflow dependent. So you may find other trainers that are resistive trainers, for example, and those trainers kind of work on the basis of, if you think about like blowing through a straw, starting with a bigger one and then going through a smaller one and a smaller one. So you’re changing the size of an orifice and changing the resistance.

Jenny Opalinski:

The difference between the pressure threshold trainers and the resistive trainers is that those resistive trainers can be affected by air flow rate, right? So you can change the diameter of the orifice, but you may be training and you may be tired one day and you may have a lot of energy the next day. And so your training can be a little bit different depending on the airflow rate that you’re producing. Whereas with the pressure threshold devices, once you set your pressure on that device, in order for you to complete a rep, you have to be able to break the seal at that set pressure. Right? So it’s important because it enables us to really know where you’re training to measure progress and to make sure ensure that we are training against a load, which is how our muscles adapt

Dr Ruscio:

And training one direction as compared to the other, it seems that expiration training is better for apnea. Is that the general trend?

Jenny Opalinski:

Actually, no. So there’s research and support of both inspiratory training and expiratory training, and maybe actually a little bit more for the inspiratory muscle strength training. But since the research is still emerging, a lot of professionals that I work with, they tend to recommend both actually. And it, like you said, it’s such a simple exercise. It does not take a lot of time. It’s not expensive. And if you are able to do it, you know, within 15 minutes, five times a week, it’s really not a lot of time out of your schedule to get the maximum benefit.

Dr Ruscio:

If someone had to pick one for the application of apnea, would you say that the inspiration or exploration training would be the better one to choose?

Jenny Opalinski:

So I think it would depend. So what the studies have shown, and there are maybe about six right now—as I said, the evidence is still emerging. There are, I believe, three studies that are just focused on inspiratory muscle strength training, and two for expiratory muscle strength training. And what they have shown for the expiratory muscle strength training, once they did a meta-analysis of those, they’ve shown improvements in the amount of apneas that a person was experiencing. So the amount of times of a person would stop breathing throughout the night. So that scale that we determine whether the sleep apnea is mild or moderate or severe could be significantly impacted if you can reduce your instances of apneas to maybe five less than usual. Because they could put you in a different category. Otherwise, for inspiratory muscle strains training, the subjects that were studied have reported that they had better sleep quality. So on measures like the PQSI. Am I saying that right? PSQI?

Gavin Guard:

Yes. And just for background, that’s the Pittsburgh Sleep Quality Index. Correct, Jenny?

Jenny Opalinski:

Correct, the Pittsburgh sleep quality index and the ESS. So that looks at daytime sleepiness. So the people who are training with us for inspiratory muscle strength training experienced improvement in those two areas. However, because the research is still emerging and still limited, we would assume that actually combining the two would be best. And depending on what your target goal is, like if you’re targeting, lowering the amount of apneas, or if you’re targeting someone who maybe has mild apnea and complains of poor sleep quality and daytime sleepiness, maybe you’d go for inspiratory.

Dr Ruscio:

So the inspiratory training looked at essentially quality of life measures or symptom measures. And the expiration training looked at apnea testing but they didn’t do a….

Jenny Opalinski:

No, I’m sorry. They looked at all measures. But where they saw the significant difference in terms of expiratory versus inspiratory were in those measures.

Dr Ruscio:

Okay, so now I’m understanding your rationale of saying “combine the two.” And really the fact that it’s the same device. It’s just an adapter. Add maybe five minutes to your daily regimen. And we’ll come to the protocol in a minute. I was doing the protocol a little bit quick. I wasn’t necessarily taking a rest breath or two in between reps, and maybe it’s a bad thing, but I was able to knock it out. I was knocking it out pretty quick, but we’ll come to the protocol in a minute to give people some idea of that. But okay, this makes a lot of sense, again, in terms of why we would combine them both. And I suppose, philosophically or theoretically, it makes sense to train both your biceps and your triceps, so to speak.

Jenny Opalinski:

Yeah. And I really think that since—like we said, there’s so much research coming out that not everything has been studied yet—but the positive outcomes that we’re seeing in both you would think that combined would be even better.

Dr Ruscio:

Sure, sure. Definitely. And so how did you find your way into this field? Do you have a background or did you have apnea yourself?

Jenny Opalinski:

So it’s super interesting. I actually am a speech language pathologist, and I was working on a research study because how I use expiratory muscle strength training is helping people to wean off of ventilators, so people who have tracheostomies and are ventilator dependent. I work with a team at a longterm acute care facility, and we approach…we have pretty good rates, but we’re trying to use every sort of therapy that we can. And we found that the respiratory muscle strength training was a great way to form an interdisciplinary team and address different goals with the same device. So I was running a research study and I connected with the owner of Aspire Respiratory Products more than a year ago and we started talking. And so I got involved as the coordinator of education and what drew me to the company was the fact that everything is evidence-based. That there is so much research. Everything that’s on that website, it’s not a sales pitch, it’s real research.

Dr Ruscio:

Right. And that’s what we saw come through the research feed. And there’s so many devices out there and I’m sure a fair number of them work. And when I say devices, I just mean that generally speaking from lasers for your skin through gizmo gadget, X, Y, Z. But what filter do clinicians like Gavin and I and yourself have to know which ones work and which ones don’t? Well science, it’s not to say it’s the end-all-be-all filter, but it is a filter that works quite well. And that’s why we really lean so heavily on that filter. So we can really bring into the clinic things that have gone through the requisite validation to ensure a certain level of effectiveness so that we’re not just assuming.

Jenny Opalinski:

Yeah. We have a lot of anecdotal stories—people feel better, they snore less, and all of this is wonderful, but at the end of the day, we also want to see that research. We want to see that we are using an intervention that has been proven. And as a medical professional, we like to see what develops and what comes. And we figured out that this expiratory muscle strength training was beneficial for people with swallowing problems, even though that’s not what it was developed for, through science, through research, through taking a look at what muscles is it affecting.

Dr Ruscio:

Yeah. And I wanted to ask you about the swallowing piece, because this is something that I’m starting to cue more so into when people mention difficulty swallowing as an indicator that apnea might be present. And I got this more so put on my radar screen in discussions with a myofunctional therapist who, when I did my own assessment—just to A) learn what it’s like and B) because I had a home sleep test with some moderate elevations—she said, “well, you seem to be swallowing okay.” And that was one of the key points of the assessment when going through a myofunctional therapy visit. And so I started connecting some of those dots, if the myofunctional therapy is so helpful for apnea, as been shown via numerous clinical trials, and this is one of the assessment components (swallowing), I’m going to start looking at that as a potential flag for apnea. But also it’s annoying for people who say, “doc, it’s so hard to take pills. I have to drink a quarter glass of water to get one pill down.” So tell us more about the swallowing piece, and whatever you feel relevant about swallowing as it maps onto apnea, and then how this device helps with the swallowing.

Jenny Opalinski:

Sure. My field is speech language pathology, but what we do is is we assess swallowing problems and we treat swallowing problems. And so very often the patients that I see may have some component of sleep apnea. So more and more so we are getting referrals in my field to work with these patients to do oral pharyngeal exercises. Because if you think about it, what’s happening when you swallow? You’re using these muscles that very much so are in the upper pharynx and those muscles are also working when you’re breathing And what is sleep apnea? It’s you stop breathing because there’s an obstruction or a collapse of the airway. And then why is that happening?

Jenny Opalinski:

Well, we think about muscle tone and we think about patency and all that stuff, and this EMST device, it’s an active treatment. And it creates positive oral airway pressure that may exercise those upper airway muscles that you need to stay open when you sleep. And various research studies that have been done on the expiratory muscle strength trainer, they show that different muscles are activated. So the muscles in the base of the tongue, for example, the muscles that raise the soft pallet, and these muscles can contribute to the airway changes that people with apnea experience. And interestingly—the last thing I’ll add there—is one of the inventors of the EMST150 device, Dr. Paul Davenport, he uses it himself. And he mentioned to me that he prefers to use it right before going to bed because the EMST will tone those muscles and retain some of that tone as he sleeps. And he feels that that helps him.

Dr Ruscio:

Right. And one other thing that I should loop in on this is there’s some evidence, if we extend this line outward a little bit, that this may enhance athletic performance, at least that’s what I’ve come together through some of your literature. I haven’t gone and done a primary literature check on this. But you know, there seems to be this line, which I want to flag for people because it’s not all about pathology and sickness. The same trend in a lot of cases line can be drawn to optimizing performance. Like you could say a cardiac rehab program could also help with your endurance capacity. I mean, it’s a loose parallel, but what can you tell us on the other side of the spectrum? So we don’t lose the people who are maybe more optimizers. What evidence or anecdotes are there here?

Jenny Opalinski:

So there is evidence that healthy individuals benefit from inspiratory and expiratory muscle strength training. Athletes, definitely. So there are studies supporting the use of both interventions in terms of helping with endurance. So with breath support, if you’re an athlete and you’re training, your breath support matters because if you’re able to sustain that breath for a longer time, you’re able to perform longer. And so we have studies on runners, on rowers, on swimmers, and handball athletes—so in all different areas—that use both inspiratory and inspiratory muscle strength training, sometimes combined (now more and more so I’m seeing). And aside from that, we have professional singers and voice users who are also using these devices. I myself, when I started working, I use it. I have my whole family using it. You know, my sister runs marathons and my other sister does some sort of endurance Pilates, but they all think it helps.

Dr Ruscio:

And that was another question I wanted to ask you. A little bit of a story prelude on this, but sometimes I’ll be at Whole Foods or at the airport and I notice that some people talk really loud. Now that might just be a lack of social awareness, but I was also reflecting on that and some of the literature about myofunctional therapy, helping those who sing the expiratory trainers, helping those who sing, the fact that there’s some evidence showing that playing woodwind instruments or singing reduces sleep apnea, and it got me reflecting on how I’m a bit more soft spoken. So maybe for me, this training device would lead to a couple things, potentially—better vocals when I do sing, better baseline speech volume. So I’m assuming that one of the things this device can help do is help with singing to some extent and also speech volume. Is that a fair claim?

Jenny Opalinski:

Well, there are studies in persons with Parkinson’s disease who have low vocal intensity who train with this device. And because it helps with subglottal pressures, it helps with improving how much air you can pull in and then push out. And the way that we make a voice is by passing air through the vocal cords, through the upper airway. So if you’re able to improve that subglottic pressure, improve the breath support, you’re able to create a louder voice and maybe sustain that voice for longer.

Dr Ruscio:

Great. So that may even help me with podcasting. Not that I’m trying to be too loud.

Jenny Opalinski:

And one other thing that I wanted to mention that may be of interest: people who are elderly, when you age—your respiratory muscles, they are skeletal muscles—so all these muscles they do weaken with age. So there is a study that shows that expiratory muscle strength training can help strengthen those muscles in the aging population. So helping with being able to stay active, right. Because you’re able to not be short of breath when you’re doing something physical.

Dr Ruscio:

Yep.

Jenny Opalinski:

That’s important, helping you to maintain a loud voice [and] safe swallow, because those things can also be affected by aging.

Dr Ruscio:

Yep. That makes a lot of sense.

Gavin Guard:

One thing that we’ve been trying to do, Jenny, is use a more cost-effective way for evaluating sleep-disordered breathing. That includes the typical obstructive sleep apnea and then the upper airway resistance syndrome. And a lot of patients are reluctant to go and do a lab sleep study, which not only is weird and invasive, having someone watch you sleep. But it’s also very expensive. And we’ve been experimenting around with a home sleep study, a WatchPAT One. And just curious to gather your thoughts as to how that may inform or give us clues of how and when either different expiratory versus inspiratory training with this EMST device.

Jenny Opalinski:

Actually, are you using these different measures that they’re looking at in the studies that we talked about? The AHI and…

Gavin Guard:

Yeah, so the WatchPAT One spits out the AHI and then the more generalized RDI. And those two are somewhat synonymous. Just trying to get your clues as like, if there’s more apneic events when someone is on their back versus on their side, is this more or less indication to use this device?

Dr Ruscio:

Or maybe a threshold that you’re finding. I know that this is a pretty particular question, but is there a certain threshold (mild, moderate, severe) for which you’re finding the device impact?

Jenny Opalinski:

Generally, studies were conducted in people with mild to moderate apnea. And in the study that looked at expiratory muscle training they noted more of a reduction in apnea in the moderate versus the mild group. And I still would love to see a study on a bigger scale, if that’s something that you are doing in your practice. That would be wonderful, to be able to know how people are progressing if they are implementing this therapy, and do the study and maybe a follow-up study to see and compare.

Dr Ruscio:

This is one of the growing list of retrospective chart reviews that we’ll likely mine maybe in another year from now. I think we’re going to have a really fruitful sort of mine to go through and pull some of this data out of.

Jenny Opalinski:

And we are happy to support any research.

Dr Ruscio:

Yeah. No, thank you.

Jenny Opalinski:

I think that’s very, very important.

Dr Ruscio:

Coming over to the protocol. It’s pretty simple. And straightforward. You want to walk us through what the protocol looks like?

Jenny Opalinski:

Sure. I’ll say this before we introduce, that this is a general protocol. It has been found to be effective, but it isn’t something that is applied every time because patients do differ or people do differ. But in general, they recommend what they’ve called the “power of fives” at Aspire. And that is five sets of five reps, five days a week. What you do is you set the device at 75% of your maximum [of] what you can do on the device. So if you don’t have a manometer, which most people don’t, but maybe you have one in office, you would check the max exploratory pressure and then start the intervention at about 75% of that. And you encourage people to do 5 sets.

Jenny Opalinski:

Now, one rep: you should be sitting up straight, you take a deep breath in and you exhale into the device. It’s very important that you have a good seal around the mouthpiece. So you’ll know the device comes with two different mouth pieces. It depends what works for you, but you don’t want air kind of coming out around that mouthpiece. And some people will use the nose clips because you don’t want the air coming out of your nose either. You want to make sure your cheeks are not puffing out because you want all that force directed into the mouthpiece. And you take a deep inhale and then you exhale forcefully enough to break the seal. So you’ll hear a woosh and I conveniently have my EMST150 right here. So I will demonstrate for you.

Dr Ruscio:

Great.

Jenny Opalinski:

*Forceful breath* I don’t if you could hear that.

Dr Ruscio:

Yep.

Jenny Opalinski:

Yep. So all my patients think it’s very funny because they’re like, “I’m just waiting for the woosh.” But it’s nice biofeedback, right? Because you broke that seal when you hear that woosh. So you do you do your five sets. It doesn’t matter [how]. Like you think about maybe an incentive spirometer where you have to sustain your inhale. [It] doesn’t matter. You don’t have to do that. You don’t get points for going faster. You should take your time, take a deep breath, a hard exhale, and then take another deep breath and do another one. Right? So it doesn’t work better if you do it faster or anything like that. And you might actually find yourself a little lightheaded if you don’t allow yourself the chance to take that breath.

Dr Ruscio:

And that’s what I figured. That’s why when I was doing it, I was thinking, “okay, probably trying to play this safe.” Me being someone that trains pretty hard, pretty frequently, I wasn’t worried about getting lightheaded and falling over. Although it would’ve been really funny if I did, I suppose, and it could have given someone a good laugh. But that’s why in my case, I just took a *quick breath*. So I went right through a breath, breath, breath and I knocked out five. And this whole thing for me took maybe less than five minutes. So it really didn’t take very long at all.

Jenny Opalinski:

And it’ll be different for everyone depending on what they can do, you know?

Dr Ruscio:

Not everyone should go that aggressive, to clarify.

Jenny Opalinski:

Not everyone should be that aggressive, but the great thing is that it is effective even when you’re not that aggressive. So I have, like I mentioned, patients who are on ventilators and it’ll take us a half hour sometimes to get through these reps, but they do it and they still get the benefit of that work.

Dr Ruscio:

Excellent.

Gavin Guard:

So the study that you guys published was utilizing this for the “power of fives,” as you put it, five reps or breaths for five sets and for five weeks. After those five weeks and someone has achieved either symptomatic or lab improvement, is there any advice that you would give as to like a maintenance mode that someone could do long term? Or is it still something that they should be doing every day?

Jenny Opalinski:

Yeah, well, it’ll depend on your training. If you’re someone who’s starting really low and trying to get to a certain level, you continue to train until you get to where you want to get. But if you’re already at a good level in your training, you want to do a maintenance protocol. And the studies show that doing three times a week (five sets of five reps) three times a week, at your last pressure that you trained at when you finished, is sufficient.

Dr Ruscio:

Yeah. That’s so, so simple, so easy. So, I mean, literally guys, this takes about, well, five minutes, depending on where you are. If you’re someone who’s very deconditioned, it probably won’t at first. But I’m assuming as people improve the condition of their muscles, it’ll be faster.

Jenny Opalinski:

Yeah. And it is really so simple and you’re getting so many different benefits. It’s great that it helps with the apnea, but also there was a recent study that shows inspiratory muscle strength training helps with blood pressure. That’s amazing. Everything’s connected. And everything’s connected to the breath, if you think about it. So your respiration can affect so many functions in the body. And so it makes sense that it would have such a wide range of applications.

Dr Ruscio:

Yeah. And there might also be an ancestral tie in here where—at least to whatever extent I am aware of this and this is not something I’ve dove deeply into but—ancestral or free living hunter gatherer bands tend to sing quite a bit. And that may be one thing that we’re missing a lot of, is singing. Or even talking. A lot of us now, I guess it depends on your profession, are talking less. So this could be, to some extent, replacing an ancestral norm that that’s not present at current day.

Jenny Opalinski:

So interesting. Yeah. It’s amazing. Really.

Dr Ruscio:

Yeah. Absolutely. And certainly we’ve had many discussions in the past about the importance of breath, and this is just one more continuation of that. Again, that could apply for athletes, artists, or people with apnea. So there seems to be a spectrum here. And especially, again, because this is not some crazy bio-hack [where] you got to spend $700 to get this gizmo. It’s 55 bucks. It’s not a huge investment

Jenny Opalinski:

And it’s not surgery. It’s not invasive. The device was created to max out at 150 and some people can max it out. But it was created at that pressure for a reason. And that was to keep it safe. If you think about max expiratory pressures, that’s what you’re training, how much force you use when you breathe out. In general people, healthy adults will have a max expiratory pressure of 80 or more. So speech requires 5-10 centimeters of water pressure. That’s how it’s measured. A cough requires 100-200 centimeters of water pressure. And a bowel movement requires 200-300 centimeters of water pressure.

Dr Ruscio:

Do you see people have any impact on constipation or bowel movements?

Jenny Opalinski:

You know, there’s not research in that area yet. But it would be interesting.

Dr Ruscio:

Yeah. Yeah. Are there any negative side effects or contraindications? Sorry, Gavin. I know this is one of the questions on your list. I’m stealing your thunder a little bit here.

Jenny Opalinski:

Yes. There are contraindications. You know, this is a device that is often used medically, but it’s also available for people to purchase. So contraindications would include people who are or might be pregnant, people with untreated and uncontrolled reflux—so keywords being “untreated” and “uncontrolled”—people with untreated or uncontrolled hypertension. And I emphasize untreated or uncontrolled because sometimes when you consider, like we mentioned the pressures that you’re exerting in your day-to-day life, sometimes if you talk to a medical professional, this may be appropriate for you, but it is something that would be done under medical guidance. Aside from that, people with abdominal hernias or recent abdominal surgery, anyone who shouldn’t perform the Valsalva, asthma patients who have a low symptom perception and suffer from frequent or severe exacerbations. It is used for people who have asthma, [they] do at times use the inspiratory and expiratory trainers. So that is, again, something that you would consult a medical professional for to be cleared. And then the last one I’ll add is a ruptured eardrum would also be a contraindication. And if you think about those pressures that you’re exerting, it makes sense.

Dr Ruscio:

Gotcha. And this device, it is available direct to consumer, right?

Jenny Opalinski:

Correct.

Dr Ruscio:

Okay. And if, if people wanted to learn more about the device and/or track you down (if you’re active online), anywhere where you point them to go?

Jenny Opalinski:

So the website is EMST150.com. We have the medical professionals side of the website also, but anyone can go on there, access it, [and] find all the research. If you sign up for the medical professional side of the site, you will have access to lot of different resources, courses. We have a lower pressure threshold device also, the EMST75 Light, that goes from 0-75 centimeters of water pressure. And that device is actually covered by Medicare. And then it’s things like a calibration chart. We have free…

Dr Ruscio:

There’s some very nice support materials. You have a nice video with how to get started, which I found very helpful. Yeah.

Jenny Opalinski:

And then if you take a look at our social media, I do run that. So you can contact me directly there. Our Instagram handle is EMST150, on Facebook we’re on as EMST150 also, and you will find us on LinkedIn under Aspire Respiratory Products. And on Twitter as EMST150.

Dr Ruscio:

Great. Well, Jenny, thank you again for the research you’ve been doing. And also obviously for taking the time out to speak with us. And I really hope this helps anyone in our audience who might need a louder voice, a better voice, maybe better athletic performance, or definitely those who are suspecting they have apnea. And again, my 2 cents on this is, even if you don’t want to be bothered by a test, you could use this protocol with or without apnea. Because again, we just discussed how you can use it for things like singing and athletic performance and see if after a month or two you notice you have a little bit better energy or mental clarity for the hefty investment of $55. Which is really, again, so reasonable.

Jenny Opalinski:

Yeah. I’m really grateful for this opportunity. We encourage people to contact us. You can send us questions, reach us via social media [and] on our website there’s an email. So we’re happy to assist and help anybody who is interested. And we have all that research available to everybody to take a look at. So you can learn more about these applications and the other applications of respiratory muscle strength training.

Dr Ruscio:

Awesome. Great. Thank you again.

Jenny Opalinski:

Thank you so much.

Sponsor:

Hi, everyone. If you are in need of help, we have a number of resources for you. “Healthy Gut, Healthy You”, my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer there is the clinic—the Ruscio Institute for Functional Medicine—and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path, health coaching support calls every other week, and also we offer health coaching independent of the clinic for those perhaps reading the book and/or looking for guidance with diet, supplementation, etc. There’s also the store that has our Elemental Diet line, our probiotics, and other gut health and health-supportive supplements. And for clinicians, there is our FFMR—the Future of Functional Medicine Review—database which contains case studies from our clinic, research reviews, and practice guidelines. Visit DrRuscio.com/resources to learn more.

Dr Ruscio:

Okay, guys. So now it’s just Gavin and I, and we wanted to discuss what we decided to do when this came through the research stream and Gavin and I were discussing this study. And, by the way, big credit Gavin. The fact that you are so intimately involved in the Future of Functional Medicine Review research feed (and for our audience, this is the kind of clinician-centered commitment that we have to publishing case studies and reviews of evidence). And also the newer feature that we’ve had there for about a year or so is the FFMR plus. And this is a summary of the most important and newly published research. And it’s lots of studies and very short synopsis of them. And what’s so nice about this is it helps me with what used to be an hour of couch reading every night. And it’s now dispersed amongst Gavin and I, and it really puts Gavin at the forefront of research. And I see how impactful that is for him because it’s something that was hugely for me.

Dr Ruscio:

So really nice example of he flags this study, we discuss it. Firstly, we make sure this device doesn’t just have one data point supporting it and might be this kind of sketchy industry funded study that looked peculiar. And that was not the case, as Jenny outlined. And then I said, “Hey, let’s both do a baseline WatchPAT One home sleep test, along with a row test, do the protocol with the expiration trainer, and then repeat the WatchPAT One home sleep test and repeat the row.

Dr Ruscio:

Now, what happened to me was I got my butt kicked out of this pseudo study. At the same time we were doing this, I was taking a cognitive peptide called Semax. And it took me a little while to figure out, but this was giving me an irregular heartbeat and it got so bad to where I was laying in bed and wondering, “what would I do if my heart stopped? Would I be able to muster enough will and speech to call in an ambulance?” So it got, it got fairly dicey. And so obviously this really derailed my plan, because I wasn’t sure at the time what was causing this irregular heartbeat. I figured out later it was the peptide, but I stopped this protocol and I stopped, obviously, the cognitive peptide. Gavin, you did go through the full protocol. So maybe you want to walk us through what your experience here was.

Gavin Guard:

Yeah. So I first did some baseline testing as you alluded to. We did that WatchPAT One—which is the device that we’re using here at the clinic—which is a home sleep test. [There were] really no issues with that. It was convenient, practical, and cheap. And what it showed was some mild upper airway resistance syndrome. So there’s two measurements that we look at, the AHI and the RDI. And long story short, I didn’t have any true sleep apnea, but the nice thing about this home sleep test was it showed a more mild (very, very mild) version of it called “upper airway resistance syndrome.” My 2K row time was good. It was where I was expecting. Now, unfortunately, I didn’t do a repeat row test to measure my respiratory fitness. So we don’t have that data point there. I did do five weeks of this respiratory protocol and I was trying to be as close to what they used in the study as possible.

Gavin Guard:

So in one of their randomized controlled trials, they did the power of fives, as Jenny alluded to, where they did five breaths, short break, times five sets. And they did that about an hour before bed. I did the same thing for five weeks. So I’m on this for about two months. I did a repeat home sleep test—and maybe we could talk about what your response was when I sent you my results—but I sent you my results and it showed that I was actually having more severe sleep apnea in this case. My RDI and my AHI went up. However, I think it’s really important to note this, subjectively, I was feeling a little bit better. So maybe we could pause here and just talk about that discrepancy between the lab findings and the subjectives there.

Dr Ruscio:

Yeah. And you know, what’s really helpful about what Jenny had said was that significant change was shown in some measures in some studies and not in some measures in the same studies. So this is one data point, and your sleep test looked worse, but if we had 20 people, the aggregate finding may have been improvements in the sleep tests. And I’m also not clear if this would be considered a statistically significant shift. I mean, you went from an AHI 2.3 to then 9, and an RDI from 6.7 to 13.8. So that, just from an eyeballing perspective, probably was a significant change. The cutoff is 15, right? So that’s one data point.

Dr Ruscio:

And this is why it’s so important as we harp on at the clinic, not to use labs as the end all-be-all measure and to also correlate clinically. And if we were doing this in a more robust fashion, we would’ve used some type of quality of life measure in conjunction with the lab finding so that we had a broader view on how [Gavin did]. Maybe the lab’s a little bit worse, but he feels better. And you can see this in SIBO. We’ve had some SIBO cases that their post-testing looked about the same, but their symptoms were pretty much gone.

Dr Ruscio:

So how do we account for this? It’s a little bit hard to say other than the fact that this is why we recommend lab testing be one-fourth of the data we use to make a decision. The other is history, symptoms, and response to treatment. So in this case, the response to treatment would really be the big thing. And, like you said, you seem to have felt better. However, placebo could also be at play there. So it’s hard to say, but I would at least take the placebo effect of you feeling better and weight your subjective improvement, symptomatically, over what the posttest shows. But this is also why it’s important to have a good clinician, because all this stuff has to be reconciled together to really come to a conclusion and we shouldn’t fret or obsess over one data point.

Gavin Guard:

Sure. And I do think, like just with any other test, there’s going to be huge interperson (meaning within the same individual) day-to-day variability. So like we joked around, if we did that same test the day after it could be totally different. We just don’t know without actually doing that experiment. But another thing is, that in the study they actually did note (on average, it’s a 25 person study) on average subjectives got better, meaning their sleep quality improved, as well as their daytime sleepiness reduced. So there is some good evidence, in this case a control trial, showing both subjectives and objectives improving. Just in my case the objectives actually got worse.

Dr Ruscio:

Yeah. Yeah. And this on the micro level also is representative of how we look at things on the macro level. Meaning if we considered you one study, we’d want to look at what the meta-analysis (the summary of many studies showed). So, you know, this does kind map on to how we recommend, “well, don’t cherry pick one study,” or in this case one finding, and at the micro level look at what the aggregate trend is. Right? So in this case, we see the labs got worse. You seem to be feeling better. And I would say, this is a win for the model of “treating the person.” It’s a loss if the model is “treating the labs.”

Gavin Guard:

Right. And fortunately this a good piggyback on to that meta-analysis that I was referring to. So I think this was actually picked up again in the FFMR plus and it was published back in last winter of 2021. It was a meta-analysis of six studies that showed that expiratory exercises such as that EMST device can reduce sleep apnea severity. And it’s a notable, a clinically meaningful, drop in that severity. So this isn’t just cherry picking. There’s actually some aggregate of multiple control trials showing some benefit here.

Dr Ruscio:

Yeah. And that’s why I felt this device had ample evidence to bring into the clinic. That one, combined with the price point, it’s kind of a no-brainer. In fact, I like this as something to consider even before myofunctional therapy and I’m a pretty big fan of myofunctional therapy. But this is really similar, in my opinion, to having someone learn to play a woodwind instrument. And I have—and I’m looking right at it, because it’s in the corner of my office—a didgeridoo and I still haven’t really learned how to play it because I didn’t want to go through the learning curve. For me, with so much going on, it was more bandwidth than I wanted to muster. But that EMS device, I banged out that protocol no problem because I just had to blow into this device and there was almost no learning curve. So it’s nice in theory to say, “learn how to play an instrument” but there’s definitely a learning curve that one has to go through and not everyone necessarily wants to trudge their way through that.

Gavin Guard:

Yeah. I actually took that device with me when I was traveling and I probably would not be able to get that didgeridoo through TSA.

Dr Ruscio:

No, no, no, no. What’s it? Four and a half feet tall? So it’s a pretty big device. What else, Gavin? Anything else here you wanted to touch on?

Gavin Guard:

Yeah, I’m calibrated with you there, Michael. I mean, I’m using this more frontline therapy. I’m using it actually, like you said, even before we do a home sleep test of say, “Hey, get started on this.” By the time we follow up on our next appointment, we’ll have the sleep test results and we’ll have 4-5 weeks on this device and see if we’re getting subjective improvements. I’m also using it in conjunction with some mouth taping, which as we both have talked about, is both diagnostic and therapeutic.

Gavin Guard:

And I’ve also played around with using the mouth taping and those nasal, those mute nasal dilators that I think Zac Cupples has put me onto, and that just ensures we’re getting enough nasal airflow in conjunction with making sure that we’re not breathing through our mouth at night. So I’m doing that with my patients and I’m personally experimenting with another device called the “EXCITE OSA” that trains your tongue muscles to get more toned.

Dr Ruscio:

Oh, did we get you one of those? I wasn’t sure if you got one in addition to myself, are you running that protocol also?

Gavin Guard:

Yeah, I actually got a sample of that. It’s my second night that I’m trying it. It more or less zaps your tongue. At first I was a little scared to do it, but it’s just like a muscle tenses unit. But in this case you put it in your mouth.

Dr Ruscio:

It’s intense. Yeah. You definitely feel it. I mean, I shouldn’t say intense in terms of it’s overly intense. But I used that overlapping the same protocol actually, and I had stopped that amongst everything else. But yeah, like a mouth guard that you wear for 20 minutes—I believe it’s 20 minutes, three times per week—which has also shown the ability to reduce apnea. And, I will say—and sorry to cut you off, but I guess I’m excited by the EXCITE OSA—I was noticing my tongue felt more kind of glued to the roof of my mouth. I got about a week and a half into that protocol, which, that’s one of the things that we want to prevent with apnea is the tongue falling back and collapsing into the throat. I’m looking forward to hearing how you feel about that device as you use it more. Now this one though, I think clocks in at about $750. Do you recall what the cost was?

Gavin Guard:

Or more.

Dr Ruscio:

Yeah, so it’s not the cheapest intervention.

Gavin Guard:

Yeah. $7500-1500, I think. It’s FDA approved. However, insurance is not picking up the bill with this. So I would say this is more last-line before CPAP, after myofunctional therapy, and definitely after something like this respiratory trainer.

Dr Ruscio:

Right. And so, just to impress upon our audience, we’re always building these things into a loose hierarchy for the individual so that we don’t just have one tool. Like I said earlier, we have many, and we’re going to personalize those to the individual. And this is what really helps us have the highest likelihood of success is having all these tools that we can pivot to and personalize for the individual.

Gavin Guard:

Yeah, absolutely.

Dr Ruscio:

Cool. Well, I think that’s a pretty good run-through, Gavin. Thanks for flagging that study. And also for running some experiments with me, even though if I was a bad study participant along with you. The next one, hopefully my compliance will be better.

Gavin Guard:

Yeah, absolutely. And one thing is, I’m so grateful that I’m part of a clinic that really values and holds highly the value of research and being evidence-informed. I think that a lot of clinicians just don’t have a lot of time to do the amount of investment research that we’re putting in here at the clinic. So I’m just grateful for that opportunity to keep on pressing forward with that.

Dr Ruscio:

Yeah, it is pretty amazing to see how much of a team we’ve built that is on top of—like sharks in the water—the research literature, but also integration of that into the clinic model, and really working together now. It’s pretty incredible to see how much more effective we’re able to be as a team. And that was one of the main goals that I had when we expanded the clinic, was making sure it wasn’t this—I’ve perhaps built up some exposure with the podcast and book and what have you—and then it’s just kind of a free-for-all inside the clinic. We’re legitimately working better as a team, because we’re doing the same model. We’re building a better model. We’re using the research, we’re leveraging our clinical experience. So blah, blah, blah. I don’t want to bore the audience, but it’s been a lot. A lot of work goes into that. It makes a really fun clinical environment, but it also does not happen without a whole boatload of work on the back end.

Gavin Guard:

Yeah. No, it’s been fun. It’s been a good experience to learn from y’all and help each other grow.

Dr Ruscio:

Yep. Love it. Well, Gavin, keep up the good work, my man. And I’ll see you around the clinic.

Gavin Guard:

All right. Sounds good. Thanks.

Dr Ruscio:

Bye bye.

Outro:

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