Breathing Dysfunction, Sleep and Airway Issues

The breathing retraining approach

Tess Graham Physiotherapist, Breathing Educator

BSc. Grad Dip Physiotherapy; Dip Buteyko Breathing Method

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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

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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

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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

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Dysfunctional breathing - asleep

•  Irregular, chaotic

•  Audible, noisy

•  Mouth-breathing

•  RR: 17-38 breaths/min

•  TV: increases

•  MV: to 20L CSA; 22L OSA

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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

Comparison

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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

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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

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Overbreathing

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Mouth-breathing

Strong correlation with

•  narrow facial structure

•  crowded, crooked teeth

•  open bite

•  gingivitis, dental decay

•  orofacial muscle dysfunction

•  aberrant swallow

•  TMD

•  bruxism

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Mouth-breathing / Airway problems

In children - directly linked to: •  asthma

•  recurrent ear infections

•  bedwetting

•  snoring

•  OSA

•  ADHD

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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)

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Overbreathing effects (1)

Physical / mechanical •  Dehydration: mucosal dryness

•  Airway trauma: inflammation, edema

•  Enlarged uvula, tonsils, adenoids

•  Vibration, turbulence, snoring

•  -ve pressure, suction, collapse

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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

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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

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Revved up nervous system

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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

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Points of view

“Open-mouth posture”

•  Restricted airway

•  Mechanical dysfunction

•  Orofacial developmental issues

“Mouth-breathing” •  All the above

•  Physiological consequences

•  Biochemical

•  Multi-system dysfunction

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Mouth-breathing

IS OVERBREATHING

What drives overbreathing?

•  Stress

•  Inflammatory diet

•  Habit

•  Need

What fixes overbreathing?

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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’

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Assessment – Observation (1)

•  Feel

•  Rhythm

•  Route

•  Nares flare

•  Sound

•  Lips and Tongue

•  Location

•  Posture

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Assessment (2)

•  Respiration rate

•  Heart rate

•  ‘Comfort’/ ‘Control’ Pause

•  ETCO2

•  Nose-breathing tolerance time

•  Symptom picture

•  3-day food diary

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Breathing retraining process (2)

Education

Exercises and strategies

Lifestyle recommendations

Review

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Goal of breathing program

Relief from Snoring and Sleep Apnea T. Graham; Illustrator © A Calvert 29

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Goal

To turn the dial back to normal 30

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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

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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

Before After

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Before After

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What you can do

Assess •  breathing pattern

•  posture

•  symptoms

•  drive to breath

•  triggers

Triage

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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

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Nose-breathing chart

DATE 10  seconds 20  seconds 40  seconds 60  seconds 90    seconds 120  seconds NOSE  BREATHER  

Example  1st  try Example  2nd  try  

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Resources Relief from Snoring and Sleep Apnea

Penguin Aus; Amazon US

Breathing Exercise Instruction Audio CD and MP3 versions – BreatheAbility.com

Practitioner Training admin@BreatheAbility.com

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