Using defibrillators; surgical robots; treating sleep apnea: Upstate Medical University's HealthLink on Air for Sunday, March 24, 2024 

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," emergency physicians explain how to use an automated external defibrillator.

Christian Knutsen, MD: ... If you bring AEDs and CPR-trained people to events, you're really trying to protect the adults as well as the student athletes. ...

Host Amber Smith: A urologist discusses the role of robots and artificial intelligence in surgery.

Seetharam Bhat, MBBS: ... The current robotic systems, it's all us doing the surgery. We control it. The robot just does the motion inside patient's body. ...

Host Amber Smith: And a sleep medicine specialist goes over alternatives to CPAP machines for sleep apnea.

Ryan Butzko, DO: ... It's implanted in the right chest, just over the big muscle in the right chest, and that device monitors your breathing and your breathing effort at night. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll explore the growing use of robots and artificial intelligence in the operating room. Then we'll learn about ways to treat sleep apnea, which don't always include a CPAP machine. But first, how CPR and automated external defibrillators are saving lives.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Last year, Buffalo Bills safety Damar Hamlin collapsed in cardiac arrest during a football game. He was resuscitated on the field in Cincinnati, and he's since recovered and was back playing football this season. He's become a big advocate for the importance of CPR and the use of AEDs, or automated external defibrillators. Before the end of the year, Governor Kathy Hochul signed into law a requirement that camps and youth sports programs provide access to AEDs.

For help understanding how these machines work and how this may affect sporting events, I'm talking with Dr. Christian Knutsen, an associate professor of medicine at Upstate and Dr. Guillermo Negrete, an EMS fellow (doctor specializing in emergency medical services) from Upstate.

Welcome to "HealthLink on Air," Dr. Knutsen and Dr. Negrete.

Christian Knutsen, MD: Thank you, Amber.

Guillermo Negrete, MD: Thank you Amber.

Host Amber Smith: Mr. Hamlin has said that by requiring at least one person to be trained to use an AED at every sports event, camp and practice, tens of thousands of kids will be protected. Is he exaggerating? Dr. Knutsen?

Christian Knutsen, MD: I'd say he's not. I think (there are) different ways of looking at that. By protecting tens of thousands of athletes, yes, I mean, obviously, all these children are playing sports at potentially large events. But in terms of protection for sudden cardiac death, the numbers are, fortunately, fairly small for children. The incidence is not that common. There's only, nationwide, we think between 2,000 and 7,000 events per year. Most of those occur at home and don't happen at sporting events. We think for sporting events themselves, there's only about a hundred cases per year. So tens of thousands are protected; the actual numbers who require it are very small.

Host Amber Smith: But in addition to the athletes, there's coaches and spectators that are older. Are they more likely to have an event?

Christian Knutsen, MD: By far. For adults, there's somewhere around 350,000 sudden cardiac deaths per year. Nationwide, that's about a thousand people per day. So compare that, a thousand per day with a hundred per year for children. Obviously if you bring AEDs and CPR-trained people to events, you're really trying to protect the adults as well as the student athletes.

Host Amber Smith: I'd like to ask you to tell us about the history of the AED. Is this a machine that was first used in the hospital before it was brought out into the public?

Christian Knutsen, MD: It was. For over a hundred years now, we've been testing electricity on the heart. We know from the 1900s that the first studies were done looking at animal models using electricity on the heart, and it could show that even back then, electricity could take a heart into rhythm and take it out of rhythm, into something called ventricular fibrillation, where the heart does not beat properly and kind of quivers. And they could show that a small shock could take it into this bad rhythm. And then a larger shock would put it back into a normal rhythm.

Fast-forward to the 1940s. There's a cardiac surgeon who is the first person to have a patient go into ventricular fibrillation during a heart surgery case. He was the first person to shock the rhythm from V-fib, or ventricular fibrillation, back into normal sinus rhythm, or a normal rhythm for the heart.

And then fast-forward to the 1960s. Dr. Paul Zoll was the first one to use a large machine on wheels. It had to weigh hundreds of pounds. It had to be wheeled into rooms. But he was the first one to show that electricity across the heart would work to fix these funny rhythms.And it wasn't until the late 1970s that we miniaturized that to a small enough portable device to use on people in the public.

Host Amber Smith: Is there data about the success rate of defibrillators used by the medical staff in the hospital compared with AEDs used by the lay public?

Guillermo Negrete, MD: I can jump in, if you don't mind. For this specific question, there's always new data coming out. This is a very big topic, and actually there is a recent article that came out in 2018, which actually shows the benefit and how important, time sensitive it is when bystanders use AEDs, prior to the patient actually getting to the hospital. And it has shown a better survival and functional outcomes in people who actually are being treated sooner, while they're in the field, before they even get to the hospital.

Host Amber Smith: Well, Dr. Negrete, can you go over the instructions for how and when to use an AED? How would a bystander know what to do?

Guillermo Negrete, MD: Sure. So, the most common scenario is when you see somebody on the ground, the first thing you're going to do is basically go and check to see if they're conscious or not, or if they're breathing or not. The most common recommendation is to call 911, put the phone on speaker and start CPR.

Obviously the ideal scenario will be to have somebody else with you, to be able to lay a hand and help you with the instructions.Whenever we use an AED, there's different types and shapes of them nowadays, but for the most part,they're standardized on the same way they are used. So, what I mean by that is, all AEDs that you use, they have three main components, which is basically some pads that are going to come in the box, and they may be either pediatric or adults. Inside, they will also have instructions. And when you are able to put those pads on the actual person, the box itself, the AED, has, for the most part, an automated voice, which can actually give instructions to you to follow.

These pads for the most part are going to be put one pad on the front of the chest on the top right, and another one on the bottom left of the chest.For the most part, we try to keep those areas clean and dry, if possible, for the machine to be able to have a better read on the patient's electrical rhythm. By doing so, the machine will activate on its own and will tell you if the patient will require or if it recommends to be shocked. If that does happen, there's a really clear, either a color or a bright button on the AED machine, which it will tell you when to not touch the patient, so you can actually push that button. The button basically will just deliver the necessary electric current into the patient before you can start continuing CPR once again.

Host Amber Smith: And these pads have to be on bare skin, is that right?

Guillermo Negrete, MD: That is correct. And again, sometimes patients, or people, they can be wet or they can be sweating. So if possible, when you remove the clothing, you can use their same clothing to kind of just wipe any excess water that the patient might have on the skin, so the actual pads can have a better touch on the actual skin for better reading.

Host Amber Smith: Is there a possible danger to using the machine by a member of the public? Could the jolt hurt someone?

Guillermo Negrete, MD: No. The answer to that is no.

Host Amber Smith: What if it's a pregnant woman? Would it hurt the baby?

Guillermo Negrete, MD: Well, in that case, the best thing to do is to save the mom to be able to save the baby.

When you have somebodyunconscious or what we call in cardiac arrest, you are not going to hurt them per se, right? Because they are, in other words, dead. So anything that you can do for this person is going to be to their benefit. That is from giving the electricity or the CPR at the same time to be able to help have a better outcome.

In regards to a bystander, if by delivering electricity to the patient, you are still touching the person, yes, you will have a jolt that can cause you to feel the electricity going to you, too. For the most part, it won't harm you, but it can cause pain because of the transfer of electricity.

Host Amber Smith: So the person using the AED may feel it?

Guillermo Negrete, MD: If you are touching the patient when delivering electricity.

Host Amber Smith: I see.

So it would be important to tell people, "get away," or "stand back."

Guillermo Negrete, MD: Correct. And the AED machine itself is very good at actually verbalizing, in a pretty good volume, telling you to please stay cleared from the patient. And even yourself, you can also speak out loud, which is a good exercise to do, to "remain clear from the patient," before you push the button on the box to deliver the electricity.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host Amber Smith. I'm talking with two emergency medicine doctors from Upstate, Dr. Christian Knutsen and Dr. Guillermo Negrete, about automated external defibrillators.

Now Dr. Knutsen, are schools in New York state already required to have AEDs on site and people trained in CPR and how to use an AED?

Christian Knutsen, MD: Yes. Schools are required. All federal buildings and state buildings are required to have AEDs in them. Ideally, they should be within a three-minute walk between any event, and where the AEDs are stored. There should be enough, depending on the size of the building, to be close by for these kind of events.

In terms of staff, at least in schools, some of the teachers need to be trained on AED use, the more the better, obviously. I know in my school district, all of the gym teachers and coaches are trained how to use AEDs, for two reasons. 1., they'll be in the school, during school hours, and 2. as coaches, if they go to events with their athletes, they'll know how to use an AED in the field as well.

Host Amber Smith: Do you know how well the machines work in extreme weather? Because here in Central New York, it could be super hot or it could be super cold. Do the machines work in extremes?

Christian Knutsen, MD: They do. They're made to work in all environments. Obviously if they're kept outdoors, the heat and cold can degrade the battery faster, which makes the importance of upkeep even more important. But they can work in all conditions.

Host Amber Smith: Now this new legislation says that camps and youth sports programs with five or more teams participating have to have an AED and at least one person trained to properly use it at the camps and games and practices. Is that going to be a challenge for teams to comply with?

Christian Knutsen, MD: It will. Obviously there are two parts to that. One is the physical purchase of the AED. So teams will have to budget to purchase the right equipment, to take care of it and travel with it and have enough AEDs on site to be safe. The second part is training. There'll have to be some pre-planning or foresight to get those folks trained on the devices and trained in CPR ahead of time, and then upkeep or update their certifications on a regular basis. I'm not sure how often that is. Likely every two to three years, so that those folks on a site are properly trained how to use AEDs and perform CPR.

Host Amber Smith: Do you have a ballpark estimate for how much an AED machine would cost someone? And then replacement batteries too, right?

Christian Knutsen, MD: They range in cost somewhere between $750 up to $3,000, depending on the model. Most, at least in my limited Google searches, were about $1,500, but there's a price range you can pick from. For upkeep, somewhere between $75 and $300 for pads and batteries, depending on the model as well.

Host Amber Smith: Now, where would coaches or parents, I guess, or umpires, where would they go to get trained in AED use?

Christian Knutsen, MD: I think there's always lots of local resources. You can always check with your local fire departments to see if they have these kind of classes for the public. You can go on the American Heart Association website, or the American Red Cross website and search for AED/CPR training, and they should have references to local sites providing this training for people.

Host Amber Smith: Dr. Knutsen and Dr. Negrete, I really appreciate you both making time to tell us about AEDs.

Christian Knutsen, MD: Thank you. Amber.

Guillermo Negrete, MD: Thank you, Amber.

Host Amber Smith: My guests have been Dr. Christian Knutsen -- he's an associate professor of emergency Medicine at Upstate -- and Dr. Guillermo Negrete. He's an EMS fellow at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Host Amber Smith: Surgeons are getting assistance from robots and artificial intelligence -- next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

More and more these days, patients who have surgery, particularly surgery on the prostate, will have their operations done with the help of a robot. Today I am talking about the advances in this field with Dr. Seetharam Bhat. He's an assistant professor of urology at Upstate.

Welcome to "HealthLink on Air," Dr. Bhat.

Seetharam Bhat, MBBS: Thank you for having me here.

Host Amber Smith: Let's start with some history about the use of robots in surgery, starting with: How do you define robot? What is a robot?

Seetharam Bhat, MBBS: So the term "robot" is actually from a Slavic root word. It basically means "associated with labor." So any machine that can perform complex tasks, that is considered a robot. So that's where it all began.

Slowly, we introduced these machines into medical field, and right now, we're at Gen (Generation) 1. So we have robots that actually mimic the surgeon's motion, but it helps us to perform surgeries in places that we cannot access with our regular hands and with our regular tools.

Host Amber Smith: So how many years ago did surgeons start using robots?

Seetharam Bhat, MBBS: So in the true sense, if you look at devices as such, so the neurosurgeons actually used it in 1908 where they used stereotactic surgery. So stereotactic surgery is a procedure where you could actually use images and precisely deliver an instrument to a point.

Either you can do manual procedures or you can actually deliver radiation to a particular point in the body using images and coordinates. So this is where it all began. That was the primitive form of robotic surgery. And then eventually we moved on, and in 1980, the orthopedicians (orthopedists) started using a device called RoboDoc, where they were able to perform orthopedic procedures.

Then the general-use robot came in in around 2000, when DARPA, which is the defense institute of the U.S. (Defense Advanced Research Projects Agency), and Stanford Research Institute, they coordinated with each other, and they were trying to build robots to be used in battlefields.

And that's when the robotic surgery actually took off, and then it was commercialized and entered into medical field.

Host Amber Smith: So a lot of times when I think about robotic assistance for surgery, I'm thinking it has to be laparoscopic, where you're not opening the patient up in a traditional way, you're just using the small incisions.

Is that the case, or do you also use robots for open surgeries?

Seetharam Bhat, MBBS: If you look at devices as such that we use currently, the robots used by the orthopedicians are kind of like open procedures, though they make tiny incisions.

So there are two kinds of robots. One is telepresence robot and the other is where you have laparoscopic instruments. So you use a regular laparoscopic instrument, and you use robots to guide and move those instruments.

The problem with those instruments is that they have no wrist in them. So the movements are not like your open procedures. While the current robotic systems that are used, the daVinci system, it's got an end-of-wrist technology, so basically it's got a wrist, so it can move in seven different directions, and you can actually mimic your movements outside, inside the patient's body.

Host Amber Smith: So if I understood you correctly, the daVinci robot has, like, an arm, like a human, and it can twist like a wrist can, in multiple directions and angles?

Seetharam Bhat, MBBS: Correct. That was a limitation with laparoscopic surgeries where we couldn't move a wrist. So we had to modify our technique in performing laparoscopic surgery. So the difficulty was in doing suturing. So that's where the wrist plays a big role. And suturing is a basic part of any surgery.

Host Amber Smith: Well, are there any other terms or milestones that we need to know about robotic assistance in surgery before we move forward?

Seetharam Bhat, MBBS: Right now, what we have is a genuine robot, so that's like a master/slave robot, where a lot of concerns which patients have, we see day to day, is that, "Are you going to be doing the surgery, or is it the robot that's going to be doing the surgery?"

That's the biggest concern which people have. The current robotic systems, it's all us doing the surgery. We control it. The robot just does the motion inside patient's body. In the future, maybe we'll have autonomous robots, so that's where we are heading, too. So we right now have a genuine robot called STAR (smart tissue autonomous robot) robot, which can perform specific tasks, but again, we control the robot.

When we say, yes, go ahead, that's when that particular robot will perform that surgery. But that's, again, in trials. It's not in clinical practice yet. So all the robotic systems that are available in clinical practice are us who are doing it.

Host Amber Smith: Are there procedures today that have better outcomes because of the robotic arms and cameras giving a better view than maybe the human eye has or being able to reach areas that it was difficult to reach compared with the traditional surgery?

Seetharam Bhat, MBBS: Yeah. The biggest example is robotic prostatectomy (whole or partial removal of the prostate). So previously for prostate cancer, people were being pushed towards radiation, and prostate surgeries were complicated because the surgeon has to reach the prostate. The outcomes weren't that great. People were leaking after the surgery. They had erectile dysfunction after the surgery.

But with the advance in the robotic technology, we are able to perform prostatectomy. And if you look at the numbers, when the robot got introduced into the market in early 2000, within two to three years, the number of robotic prostatectomies skyrocketed.

We were performing thousands of surgeries every year, while prior to the robot, we were performing like hardly 500 to 600 surgeries in a year. So this particular procedure actually benefited from the robot.

Host Amber Smith: Are there particular surgeries that just physically couldn't be done because human hands were too big to get into the space before the robots were available?

Seetharam Bhat, MBBS: Yes. Some procedures by the cardiothoracic surgeons, where they couldn't put their hands in the chest, we were using robots. Cardiothoracic surgeons also were using robots to harvest LIMA -- LIMA is "left internal mammary artery." So they were able to harvest that, which they physically were not able to do with the hands.

Host Amber Smith: Do surgeons miss out on anything by not being able to feel the way they would have if they were doing the surgery with their hands? They're not able to feel things, right, if the robot is doing that part?

Seetharam Bhat, MBBS: That's called haptic feedback. One of the biggest criticisms was, in the initial generation of robots, there was no haptic feedback, so we cannot feel stuff.

But as surgeons, we've learned how the tissue moves, how the tissue behaves with the regular instruments, and that itself was a feedback. So we've got visual feedback from the way the tissue handles, so it's really not a problem, but yes, there is a newer system called TransEnterix robot that has this feedback where you can actually feel the tissue. They have sensors at the tip of the instruments, which the surgeons can feel.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking about the use of robots in surgery with urologist Dr. Seetharam Bhat.

In a lecture recently, you said that the prostate saved robotic surgery. What did you mean by that?

Seetharam Bhat, MBBS: Initially, when the robot was introduced, it was introduced to be used in cardiothoracic surgery, but then the cardiothoracic surgeons were using it to harvest LIMA, that is, the left internal mammary artery, and then they were performing open surgeries on the heart. And for some reason, they did not adopt the robotic surgery.

So most of these robots were just lying in these universities without being used. That's when a urologist, Dr. Mani Menon from Vattikuti (Urology) Institute (in Detroit), decided to use this robot in prostate surgery.

So it was not initially FDA (Food and Drug Administration) approved for prostate surgeries, and most of these centers were not using them. But once he showed how prostatectomy can be done with this robot, there was a quick adoption of this technology, and multiple centers started doing robotic prostatectomy, so that's why we say that robotic prostatectomy saved the robot technology, and there was widespread adoption.

And we have like 3,000 installations currently in the country, more than 3,000 installations.

Host Amber Smith: Why are robotic prostatectomies performed five times more than traditional open surgeries?

Seetharam Bhat, MBBS: It's the technical challenge. The prostate is an organ that sits below the bladder in the patient's pelvis, so pelvis is the bony cage which protects your bladder and the prostate.

In order to reach the prostate, we have to dig our hands underneath the bladder and reach the prostate. And prostate is often a walnut-size organ. It's tiny. It's tough for us to see it. Tough for us to feel it. Tough for us to dissect it. With the robot, we have 10 x magnification. You see things clearer, things are magnified, the instruments are more precise. We can perform the procedure more precisely.

Host Amber Smith: It sounds like there's a lot of advantages. Are there ever patients for whom a robotic procedure is not recommended, where you would say they really just need an open surgery?

Seetharam Bhat, MBBS: Right now, the indication for robotic prostatectomy is widespread.

So you can pretty much offer it to all the patients. Before, there was a limitation. Obese patients were not being operated upon, but we found that robotic surgery safe in them.

The only instance where we probably would not consider robotic prostatectomy and try to do a perineal prostatectomy is in patients who've had multiple surgeries in the past.

With multiple incisions in the abdomen where you expect a lot of scar tissue, a lot of bowel adhesions (bands of scar tissue), then we change our approach. We don't go through the abdomen, we go through the perineum, which is behind your scrotum and in front of your anus. So we make an incision and reach the prostate via that particular route.

Host Amber Smith: There's multiple companies that make surgical robots today. Is there any standardization between them?

Seetharam Bhat, MBBS: The daVinci robot, which is the current existing system, most common system that we use in the U.S., had all the patents for it, and now it's been 20 years, and the patents are kind of expiring, so we see all these other companies bringing in their own versions of the surgical robot.

What did daVinci achieve? It showed us that the robot has a use in medical field, and it proved that robots are safe. These were the two values which daVinci did in the last 20 years.

Now since, the patents have expired, there are many companies that are bringing in. There is a company called CMR Robotics, which has its own version of robot. They're based out of London. Medtronic, which is a huge medical company in the U.S., they've brought their own robot.

They all have similar principles in the way they operate, but they're slightly different.

Like, daVinci is a single robot where all the arms come out of a single pole, while Medtronic's robot, the arms are individual, so you can position them at different spots, so you can configure how the robot works. Same with the CMR. The arms are different, so you can place one arm at the head, one arm at the leg of your patient, one arm at the side, but in the daVinci, it's a single pole, and then multiple arms come out of the single pole.

Those are minor differences, but they all have risk. They all have similar instruments. Nobody's going to change the technique just because you have a new company releasing a new robot with fundamentally different design. So designs are almost the same. It's just that they're a little different.

Host Amber Smith: I see. Now, we talked about prostate, we've talked about cardiac. What other types of surgeries lend themselves to being done with robotic assistance?

Seetharam Bhat, MBBS: Right now, almost all general surgeons are using the robot: cholecystectomy (gallbladder removal), they're doing bowel surgeries. Rectal surgeries, again, rectum is an organ that's in the pelvis, that's behind the bladder, so those surgeries are performed using the robot. Thoracic surgeons use it to perform lung surgeries. There are different models of robot used by the orthopedicians. There is Mako robot that helps in arthroplasty (restoring a joint). We can replace hips with that. You have some robots that are specifically designed for the spine.

There are multiple other companies with different designs for other surgeries, too. So more or less, all the surgical procedures now have a robot attached to it.

Host Amber Smith: Are we looking forward to a day when the robots do the procedure entirely?

Seetharam Bhat, MBBS: That is where it's heading to. Right now, if you look at the autonomy of the robot, autonomy is where you let the robot perform tasks by itself, there are levels of autonomy. We got this concept from self-driving cars.

Right now, all the robots that are available are Level 1 robots, where it's a master, that is, us, surgeons, who are operating the robot. And the robot will kind of mimic our actions.

The Level 2 autonomy is when you have specific tasks, which the robot will perform. They don't perform the entire operation, but we give them permission, and they would perform a particular task, like either suturing or cutting a particular tissue or making an incision in the abdomen. So it'll perform a specific task.

In Level 3 autonomy, we expect the robot to perform more complex tasks, but it's us deciding whether the robot performs it. So it can perform the entire operation, but it's us saying, OK, go ahead. And we have a level of autonomy, meaning we kind of control these robots, and we can override these robots.

Level 4 is when they do it all by themselves, so we have no control. So they make the decision. If the patient has to undergo the surgery, they will perform the surgery, and then they will manage the outcomes and everything. So it's all done by them, and we cannot override them. So this is Level 4 autonomy. Right now, we are at Level 2. We have robots that are being trialed to perform specific tasks.

Host Amber Smith: What is augmented reality in relation to surgery?

Seetharam Bhat, MBBS: So if you look at augmented reality in general terms, it's basically you're using computer-generated simulation and using it in real world.

So there are now multiple companies with different products where we can use patient's images intraoperatively and overlaid on the surgical field. So there is a company called Ceevra. So what it does is, they use patients' images, create a 3D model of, say, for the prostate, the surrounding structures, the lymph nodes around the prostate. And you can use these 3D models in the current robotic system, and you can kind of superimpose them side by side and know patients' anatomy.

Again the TransEnterix robot, which I told you, they have tools where they can superimpose these images onto the patient. You can actually measure stuff inside patients' bodies. So they actually have a ruler, and you can measure, say, I have to go 5 centimeters towards the prostate. I can measure how far I'm moving using those rulers.

So it's heading towards that. It's basically like using Google Maps inside the patient. You know how to do, where to go, how to find the anatomy, how to perform the operation.

Host Amber Smith: Well, how would you like to see robots evolve in the field of medicine?

Seetharam Bhat, MBBS: Well, I am a fan and a skeptic both together at the same time.

I like the fact that we are having so many other tools that will enhance our ability to perform procedures. But at the same time, I worry about patient safety.

Like, for example, right now, AI (artificial intelligence) is a big thing. People are talking about AI. When ChatGPT was launched, it was able to answer almost all the questions with accurate answers, so it could solve a math problem with 98% accuracy, but over time, now the accuracy is going down because it's learning all the other stuff on the internet. So recently they published a paper where it could only accurately solve a problem about 2% of the times.

So this can happen even with the surgical robot. If you have a new surgeon or a trainee resident trying to perform surgeries, and the machine learns that, over us, there is no control as to what the machine is learning. That's the problem with AI. You just feed large data sets to the machine, the machine learns. It cannot pick and choose which is right, which is wrong. It just learns based on what is being fed to it.

So that's where I think the patient safety has to be taken into consideration, and we still have to have some control. The Level 4 autonomy is something that scares me.

Host Amber Smith: I was going to ask if you would be comfortable having a robot do your surgery on you at a Level 4 status or whatever.

Seetharam Bhat, MBBS: If you speak to the scientists who are actually supporting AI, they will tell you it's the same question with self-driving cars. You can use self-driving cars as an example in surgical robots. Would you let a car drive you home?

But they would support self-driving cars with data. They're saying the number of accidents are lesser when the car is driving itself rather than human beings driving the car. So the human error forms a big part in this. The same thing with the surgery, too. The idea of using autonomous robots is to eliminate human error. That's when I think experience comes into play.

This is a little bit nuanced. You need to have experienced surgeons performing surgery, so the surgical error is much lesser. That's why we have tools like proctorship (monitoring and evaluation), we have training, we have to undergo training for almost 10 years before we actually can start performing surgeries on the patient.

That's the difference. I'm skeptical about the future with regards to patient safety. At the same time, I am excited about all these technologies.

Host Amber Smith: You've given us a lot to think about. I appreciate you making time for this interview, Dr. Bhat.

Seetharam Bhat, MBBS: Of course. Thank you.

Host Amber Smith: My guest has been Dr. Seetharam Bhat, an assistant professor of urology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," CPAP alternatives for treating sleep apnea.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

One of the most common treatments for sleep apnea is positive airway pressure. For help understanding this treatment, I'm talking with Dr. Ryan Butzko. He's an assistant professor of medicine at Upstate, and he specializes in sleep medicine.

Welcome to "HealthLink on Air," Dr. Butzko.

Ryan Butzko, DO: Hi, Amber. Thank you so much for having me.

Host Amber Smith: Before we get into positive airway pressure, can you please describe sleep apnea, what it is, whom it affects?

Ryan Butzko, DO: Yes. Obstructive sleep apnea is a disease for when you go to sleep, your muscles of your upper airway relax, and it causes either partial or complete blockages to breathing that may or may not be associated with decreases in oxygen throughout the night.

Host Amber Smith: So is it people who stop breathing in the middle of the night?

Ryan Butzko, DO: Yes. Simplified, it is people that stop breathing, and it's due to a blockage in the airway or in the back of the throat that causes the blockage to breathing.

Host Amber Smith: Most times, do people wake up on their own, or is that how people die from sleep apnea?

Ryan Butzko, DO: It's extremely rare to actually die from an apneic event, but it is one of the common causes in obstructive sleep apnea that causes people to wake up in the middle of the nights. Often what'll happen during a partial or complete blockage to breathing is the body will start to increase muscle tone to the upper airway so that it can open up the airway on its own.

And if it cannot do that while you're asleep, the last bailout that it has is to wake you up, and you wake up and kind of gasp for a breath of air.

Host Amber Smith: So how does a person know, or how do they find out, that they have sleep apnea?

Ryan Butzko, DO: The way to get tested is to do a sleep study, and that's the only way that we have right now to diagnose you.

But we do have a fairly extensive amount of sleep studies. The first one that has been done, and the most comprehensive, is something called a polysomnogram, or an in-lab sleep study, where you come into the lab and spend the night. We hook you up to some monitors so that we know when you're sleeping, hook you up to some other monitors, to know when you're breathing and when the blockages to breathing occur, and monitor you throughout the night.

The other tests that we have are something called a home sleep test, of which there are plenty of variety. The best one that we use is a modified version of the in-lab where you take a recording device home that monitors blockages to breathing and your oxygen saturation.

Host Amber Smith: Now, if someone is told that they snore at night, is that something that they need to be concerned with, that maybe they've got sleep apnea?

Ryan Butzko, DO: Snoring by itself does not necessarily diagnose you with sleep apnea, but it is one of the most common markers of sleep apnea. And I'll tell you that it's probably the most common reason that people come to see me in the clinic. If you just have snoring, you may have sleep apnea.

But it really increases the risk if you have other symptoms, like excessive sleepiness during the day. Or when you wake up, you don't feel refreshed at all, or you're waking up frequently during the nights, maybe in a panic or choking and gasping, and you don't know why.

Host Amber Smith: So if someone suspects that they have sleep apnea, they need to get these tests to find out for sure.

Are there simple lifestyle changes that they can do to nip it in the bud?

Ryan Butzko, DO: The biggest association we have with sleep apnea is weight related, so the best lifestyle change that anyone can do is try to lose weight. And when we're talking about weight change, it varies from person to person, but generally speaking, a weight loss of about 20 pounds is usually significant and can sometimes cure people of sleep apnea or at least reduce the severity quite significantly.

Host Amber Smith: Well, let's talk about what positive airway pressure is, and how does it help?

Ryan Butzko, DO: Positive airway pressure -- shortened version of it is CPAP, which stands for continuous positive airway pressure. And what it is, is a machine that provides a little bit of airflow at a certain pressure that we prescribe, that's connected to a tubing and a mask that's connected to your face. The pressure that it provides keeps your airway or the back of your throat open, in order to prevent the blockages to breathing that lead to the apneas or the apneic events.

Host Amber Smith: So it's different than putting a mask over your face for oxygen.

This has pressure behind it.

Ryan Butzko, DO: That's correct. So an oxygen mask just provides a little bit of increase in oxygen. This provides an increase in pressure, and it has a mask that has to have a nice, firm seal. Otherwise, the airflow leaks out, and the pressure is gone.

Host Amber Smith: It doesn't sound like it would be very comfortable to have pressurized air going into your throat. Do people just get used to it?

Ryan Butzko, DO: Yes, so that's probably the most common question that I'm asked in my office. Most people need a period of time to acclimate to the device. My own father, who uses CPAP religiously and swears by it and cannot sleep without it anymore -- he loves it, and it took him, he told me, about four weeks to get used to the machine.

It's a different sensation while you're sleeping, especially when you wake up, and you have something foreign on your face. So it absolutely takes time to get used to, but once you start to notice the benefits, especially a better quality of sleep, more energy during the day and feeling more rested, it's a lot easier to buy in.

Host Amber Smith: So this is called CPAP, but I've also heard of BiPAP. What is that and how does it differ?

Ryan Butzko, DO: So BiPAP is just a different form of positive airway pressure. It stands for bi-level positive airway pressure, and it's quite simple. Instead of CPAP, which is one continuous pressure, BiPAP is two pressures.

You have one pressure, that's the bottom pressure, that is continuous throughout the night, and then when you take a breath in and the machine senses that you take breath in, it will switch on and kick on to that higher pressure. It can be beneficial for some people with sleep apnea. Some people cannot tolerate higher pressures during the night, and this provides a little bit of a break during the breathing cycle to allow you to have lower pressures when you exhale and just higher pressures when you need them.

It's also a big benefit for people that have something called CO2 retention, or carbon dioxide retention. So if you've ever been told by your doctor or ever been in the hospital and been told that you have elevated carbon dioxide levels, a BiPAP machine can help increase the volume of air that you breathe at night and help you eliminate the carbon dioxide while also providing a modest increase in your oxygen levels at night as well.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Ryan Butzko, who specializes in sleep medicine at Upstate, and we're talking about CPAP machines for people with sleep apnea.

Once you have a patient on the machine who's happy with it, it's working well, are they done seeing you, or do you continue seeing them regularly?

Ryan Butzko, DO: Generally speaking, once they're set up, and they're good to go, and I see that their sleep apnea is well treated, and the way that I can see that they're well-treated is the machine can actually monitor the blockages to breathing through some of the technology that they have in the machine.

It's connected to WiFi, and it sends the data to a website, which I can log in and check on the compliance to make sure that you're using it and see how well you're treated and make sure that the number of blockages to breathing, which is called the AHI number, or apnea-hypopnea index, is within the normal range, which is five or less, during the night.

Once they're well treated, and they're doing OK, I generally just do an annual follow-up. Most of the time the insurance requires just an annual follow-up to make sure that you're using the machine, getting benefit from the machine, for the medical equipment company to keep sending you supplies.

Host Amber Smith: That's pretty interesting that the doctor will know if the patient is using the machine and using it the right way all night long.

Ryan Butzko, DO: Yeah, it's a little bit like Big Brother. So you can't lie in this circumstance because I will know if you're using the machine or not.

But my goal is not to berate anyone for not using the machine. If you're not using it, and you're not comfortable, we work together on a way that you can be comfortable with the therapy.

Host Amber Smith: A variety of CPAP alternatives are on the market, and I'd like to ask your opinion of these products.

Is there anything that you recommend if CPAP just doesn't work for someone? They try it for four weeks, and they just can't get used to the mask or the pressure.

Ryan Butzko, DO: Unfortunately, that is a very true reality of this machine. It is extremely, extremely effective, but even the most effective treatment, if not used, is still a failure.

So we do our best to try to get you used to the machine, try different mask interfaces -- some are more comfortable than others -- and try to improve the comfort settings on the machine to get you used to it. But some people just can't do it. So after that, we try to get a little creative.

For those with more mild sleep apnea, there's something called an oral appliance or a mandibular advancement oral appliance. These devices are made specifically by a dentist that's specifically trained in the making of the devices for sleep apnea, and what the device does, it's like a retainer-type device that's molded to your own teeth that moves the lower jaw slightly forward to give you more room in the back of your throat to breathe and prevent the blockages to breathing.

Again, it's much more effective in mild to low-moderate sleep apnea. If you have high-moderate to severe sleep apnea, it's probably not going to be enough.

One of the second things that I do is, we look and see, on your sleep study, what position that you're sleeping in, the sleep apnea gets worse.

And more often than not, sleeping on your back is the worst position and makes you most susceptible to have the blockages to breathing at night.

Sometimes even a simple positioner device is enough to treat sleep apnea, to get it at least into the mild range or even get rid of it completely, some of which are sold commercially, but even so, I have some do-it-yourself patients that just stick pillows under their back or sew things into the back of their shirt to prevent them from going on their back at night. So for the mild to low-moderate sleep apnea people or someone that's very position dependent, these are some creative options that I sometimes recommend, if they can't tolerate CPAP, that can be fairly effective.

Host Amber Smith: I've seen TV ads for something called Inspire, and it advertises, "no mask, no hose, just sleep." It sounds too good to be true. How does it work?

Ryan Butzko, DO: So I have extensive experience with Inspire. It was a big part of my fellowship and training. So what this is, and what the commercial doesn't tell you -- I think it's intentionally vague for a reason, just to get people talking about it -- it is a surgical implant, and the device is surgically implanted by an ENT (ear, nose and throat) surgeon.

And one part of the device is something very similar to a pacemaker. It's implanted in the right chest, just over the big muscle in the right chest, and that device monitors your breathing and your breathing effort at night.

It also has little wires that are connected to the nerve that controls your tongue, which is called the hypoglossal nerve. That nerve is primarily responsible for tongue movement. When the device is implanted, and it senses that you're taking a breath in, it will send an impulse to the electrodes around the nerve that controls the tongue, telling the tongue to move forward, and thus, theoretically, moving the tongue out of the back of the throat and increasing the area, in order to make you breathe and prevent blockages to breathing.

Host Amber Smith: So are there anatomical reasons that this might work for someone and maybe not be the best thing for someone else?

Ryan Butzko, DO: Yes, absolutely, and during the course of getting you qualified for such a device, the ENT surgeon does something called a drug-induced sleep endoscopy; we shorten it to something called DISE. It puts you kind of in a twilight state, where you get sleepy, and they take a camera and look at the back of your throat and look to see where the back of your throat collapses or where your airway collapses to determine if you have a favorable anatomy for this device.

Host Amber Smith: So how big of a surgery is this to have it implanted? Is it a one-day, kind of in-and-out thing? And then once it is implanted, how soon does it start working, and would someone notice a difference?

Ryan Butzko, DO: It is a same-day surgery. So if you ever had a same-day surgery, you go in, the surgery itself is probably about 90 minutes, on average.

It does require general anesthesia, and it requires you to be on a ventilator for that time, partly because of where they are working and partly because people with sleep apnea are at increased risk for surgical procedures just by the general nature of the anesthesia. Once the device is in, you come out, you generally leave that same day.

Most importantly, you need to wait for the nerve that controls your tongue to heal before we even turn on the device. So you will follow up with a sleep physician four weeks, generally, after the surgery, and at that time we'll assess the nerve healing, and only then will we actually turn on the device.

So in that four weeks, the device is not on and not working. So whatever you were previously using for your sleep apnea, you need to continue before we turn it on.

Host Amber Smith: What happens to someone who has sleep apnea and doesn't do anything for it, doesn't want to deal with the machine, isn't interested in this surgery, just wants to be left alone. Is it dangerous to have sleep apnea go untreated?

Ryan Butzko, DO: It's a good question and something I get asked all the time. So sleep apnea can be dangerous in the same way that you may have heard that high blood pressure is dangerous or diabetes is dangerous over a long period of time.

Sleep apnea can lead to the development of many, many other diseases, and the list is so long and involves so many other organ systems that I can't list them here, but the most dangerous ones are high blood pressure, coronary artery disease or heart disease, heart failure, stroke and arrhythmias, which are abnormal heart rhythms.

Those are the most dangerous complications of sleep apnea. They do take time to develop, but they are highly, highly associated with sleep apnea. If you are untreated, and if your doctor has told you you're in the moderate to severe range, that is the range of sleep apnea that puts you most at risk for developing these complications.

And you should be treated, whether it be with CPAP, whether it be with an oral appliance, whether it be with Inspire, or even really, really trying to lose weight. Any of those things can help.

If you're in the mild range, your risk of developing these things is more or less the same as the general population that doesn't have sleep apnea, so it is not imperative that you need to aggressively treat it. People with mild sleep apnea, I generally only push for more aggressive treatment if they are very symptomatic with regards to their sleepiness or poor functioning during the day or poor quality of sleep at night.

Host Amber Smith: Well, that's important to know. Thank you so much. I appreciate you making time for this interview, Dr. Butzko.

Ryan Butzko, DO: Yes, it was great. Thank you for having me.

Host Amber Smith: My guest has been Dr. Ryan Butzko, a sleep medicine specialist at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Kathleen Goldblatt is a poet who describes visiting her mother in assisted living. Here is "How I Take Care of My Mother."

I walk down the long hall to my mother's room

past dining tables, past cloned rooms,

to where she sits in her worn-blue lift chair,

bend to kiss the tissue-paper skin of her forehead.

We begin the game --

How are you? I'm fine. We're experts.

She wants everything tidy.

I straighten what I can, put away

pink flannel pajamas, clean the cup at her sink.

Drop into the empty wheelchair.

I ask about the chicken she had for lunch,

ask if I can turn on the television. Noise

fills holes. I want her to say no, act annoyed.

I want her to curse. An aide comes in and tells me

how nice my mother is. Niceness can be

a burden so heavy even Atlas wouldn't carry it,

I'm fine can be a conspiracy of lies.

She told me once how she climbed a tree

when she was young, how she refused to come down

for hours. Sometimes people hide so long

they forget they want to be found.

Pictures line her dresser, the window sill, a small table --

a family of skilled smilers. Tiredness creeps in,

I fix us both a cup of tea. I'm swimming across a lake

not sure there is another shore. I keep swimming

because she is old, because she won't come

down from a tree. I want to know if she is afraid

of death. I promise to come back tomorrow,

prop the door, say, I miss you. The only truth I tell.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," rates of syphilis are on the rise.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.