dental sleep- breathing retraining - spreecast tess graham - raphael center - oct 2014
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Breathing Dysfunction, Sleep and Airway Issues
The breathing retraining approach
Tess Graham Physiotherapist, Breathing Educator
BSc. Grad Dip Physiotherapy; Dip Buteyko Breathing Method
1
Physiological norm – awake
• Rhythmic, regular
• Silent
• Nasal
• Diaphragmatic
• RR: 8-12 breaths/minute
• TV: 500 mls/breath
• MV: 4-6 litres/minute
• CO2: 40-45mmHg
2
Physiological norm – asleep (1)
• Nose-breathing
• Diaphragmatic
• Regular -NREM; some irregularity-REM
• RR: some increase in REM, NREM
• TV and MV reduce
• Decreased tone pharyngeal dilators
• O2 asleep < awake
• CO2 increases 3-7mmHg
3
Dysfunctional breathing - awake
• Irregular – sigh, yawn, cough
• Audible, noisy
• Mouth-breathing
• Upper-chest breathing
• > 14 breaths/minute
• TV - 950 mls/breath OSA
• MV - 8.8 L/min ‘simple’ snorers
- 15 L/min OSA
- 14L/min OHS
4
Dysfunctional breathing - asleep
• Irregular, chaotic
• Audible, noisy
• Mouth-breathing
• RR: 17-38 breaths/min
• TV: increases
• MV: to 20L CSA; 22L OSA
5
Comparison
Normal Sleep apnea Respiration Rate 8-12 16-38 (Graham)
Tidal Volume 500mls 950mls (Radwan)
Minute Volume 4-6 L 13L (Awake – Esquivel CSA)
14L (Awake - Redolfi OHS)
15L (Awake - Radwan OSA)
20-22L (Asleep - Xie, Graham) Insp. Flow Rate 280mls/sec (Douglas) 620 mls/sec (Radwan)
CO2 40-45mmHg Hypocapnia, Hypercapnia, Normocarbia 6
Overbreathing and disease
• Asthma 14 L/min (Bowler)
• Heart disease 15 L/min (Dimopoulou)
• Diabetes 15 L/min (Tantucci )
• Epilepsy 13 L/min (Esquivel)
• Panic disorder 12 L/min (Pain)
• Obstructive Sleep Apnea (OSA) 15 L/min (Radwan)
Normal breathing 4-6 L /min
9
How ‘normals’ breathe today
Dr. Artour Rakhimov (www.NormalBreathing.com
Dr. Artour Rakhimov (www.NormalBreathing.com) 10
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What disturbs breathing? • Stress
• Coughing, crying
• Over-heating
• Over-eating
• Poor diet (inflammatory)
• Illness, infection
• Slumped posture
• Mouth-breathing habit
• Wrong advice, faulty instruction
11
Mouth-breathing
Strong correlation with
• narrow facial structure
• crowded, crooked teeth
• open bite
• gingivitis, dental decay
• orofacial muscle dysfunction
• aberrant swallow
• TMD
• bruxism
14
Mouth-breathing / Airway problems
In children - directly linked to: • asthma
• recurrent ear infections
• bedwetting
• snoring
• OSA
• ADHD
16
Carbon dioxide Roles:
• balances and regulates pH
• stabilises mast cells
• regulates breathing
• synthesis antibodies, hormones, enzymes
• calms nervous system
• smooth muscle dilator
• facilitates release of oxygen (Bohr effect)
17
Overbreathing effects (1)
Physical / mechanical • Dehydration: mucosal dryness
• Airway trauma: inflammation, edema
• Enlarged uvula, tonsils, adenoids
• Vibration, turbulence, snoring
• -ve pressure, suction, collapse
V Lunn-Rockliffe 2014 18
Overbreathing effects (2)
Physiological / biochemical • mast cells leak histamine
• smooth muscle spasm
• tissue hypoxia (Bohr effect)
• adrenaline, cortisol increase
• sympathetic nervous system stimulated
• blood pH increases
• central apnea, hypopnea
• mixed apnea
• instability in central control
19
Effects of low CO2 on the brain
40% reduction in O2 after 1-minute hyperventilation
MRI Scan: red = most O2 dark blue = least O2 Litchfield1999
20
Symptoms of overbreathing Neurovascular: Central: disturbances of consciousness, faintness, dizziness, unsteadiness, impairment of concentration and memory, feelings of unreality, "losing mind" Peripheral: Paraesthesia, numbness, tingling and coldness of fingers, face and feet
Musculoskeletal: diffuse or localised myalgia and arthralgia, tremors and coarse twitching movements, carpopedal spasm and generalised tetany (infrequent)
Respiratory: cough, chronic throat tickle, shortness of breath, atypical asthma, tightness in or about chest, sighing respiration, excessive yawning
Cardiovascular: palpitations, skipped beats, tachycardia, atypical chest pains, sharp precordial twinges, dull precordial or lower costal ache, variable features of vasomotor instability
Gastrointestinal: oral dryness, globus, dysphagia, left upper quadrant or epigastric distress, aerophagy, belching, bloating, flatulence
Psychological: anxiety, tension and apprehension, inappropriate pseudocalmness (hysterical subjects)
General: nocturia, easy fatigability, generalised weakness, irritability and chronic exhaustion, frightening dreams, sleep disturbances
Adapted from Breath Connection - Fried R. 1990
22
Points of view
“Open-mouth posture”
• Restricted airway
• Mechanical dysfunction
• Orofacial developmental issues
“Mouth-breathing” • All the above
• Physiological consequences
• Biochemical
• Multi-system dysfunction
23
Mouth-breathing
IS OVERBREATHING
What drives overbreathing?
• Stress
• Inflammatory diet
• Habit
• Need
What fixes overbreathing?
24
Breathing Retraining
Restoring a physiologically normal breathing pattern
• breathing at the correct rate and rhythm and volume
• with the correct use of the breathing muscles
• at rest, during activity, speech, sleep and sport
• retraining respiratory centre’s breathing ‘set point’
25
Assessment – Observation (1)
• Feel
• Rhythm
• Route
• Nares flare
• Sound
• Lips and Tongue
• Location
• Posture
26
Assessment (2)
• Respiration rate
• Heart rate
• ‘Comfort’/ ‘Control’ Pause
• ETCO2
• Nose-breathing tolerance time
• Symptom picture
• 3-day food diary
27
Breathing retraining process (2)
Education
Exercises and strategies
Lifestyle recommendations
Review
28
31
Nine healthy breathing habits 1. Awareness
2. Nose-breathing
3. Upright posture
4. Regular breathing
5. Diaphragm breathing
6. 8-12 breaths per minute
7. Silent invisible breathing
8. Breathing control during speech and singing
9. Breathing well during exercise
Relief from Snoring and Sleep Apnea ©Tess Graham
32
Efficacy
Before and after • Breathing assessment
• Symptom Trackers
• Partner / parent observations
• Capnometry
• Sleep studies
Case Study
Age 14
100% mouth-breather
Upper chest
Audible breathing
RR 16
HR 83
CP 17 secs
NBT 11 secs
Sleep apnea 33
Symptom Tracker Symptoms Assessment 1 Assessment2 Assessment 3 Assessment 4
Day 2 Day 5 Day 14
Sleep apnea observed XXXX XX X
Heavy, irregular breathing in sleep XXXX XX XX --
Toilet visits overnight 1 1
Waking with gasp 2-3
Blocked nose XXXX X
Waking with dry mouth XXXX XX X
Restless legs XXX XX X
Breath holding in day, sighing, yawning XX
Short of breath – resting XX
Frequent urination XX
Poor concentration XX X X
Mouth-breathing - night XXXX XXX XX XX
Mouth-breathing – day XXXX XX
Total symptom score 39 16 8 2
% reduction symptoms 59% 79% 95% 34
What you can do
Assess • breathing pattern
• posture
• symptoms
• drive to breath
• triggers
Triage
37
38
Triage
Category 1: awareness and nose-breathing practice – mouth-breathing – habit, not need
– easily wear appliance
Category 2: refer to breathing educator – mouth-breathing – need and habit
– mild-mod overbreathing and symptoms
– struggle to wear appliance
Category 3 : refer to (Buteyko-trained) breathing educator – mouth-breathing entrenched
– chronic overbreathing, mod-severe symptoms
– co-morbidities
– struggle/ cannot wear appliance 38
Teaching basic skills
• Awareness, understanding
• Nose-breathing practice
• ‘Unfold’ posture
• Less sugar
• Sleep position
39 V Lunn-Rockliffe © 2014
Nose-breathing chart
DATE 10 seconds 20 seconds 40 seconds 60 seconds 90 seconds 120 seconds NOSE BREATHER
Example 1st try Example 2nd try
40
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