ST. JOHN HOSPITAL
’’SLEEP”
JULY 2015
DR. RICHARD E. KLEIN
THE VARYING
ROLES OF THE
NOSE AND MOUTH
IN BREATHING
OBJECTIVES
1. REVIEW ANATOMY AND PHYSIOLOGY
OF NOSE
1. EXPLAIN NASAL FUNCTION
2. RELATIONSHIP OF MOUTH BREATHING
TO OBSTRUCTIVE SLEEP APNEA AND
SNORING
3. FUNCTIONAL CONSEQUENCES OF
MOUTH BREATHING
4. PHYSIOLOGICAL CONSEQUENCES OF
MOUTH BREATHING
HUMAN BEINGS ARE
DESIGNED TO BE
NASAL BREATHERS
THE IMPULSE TO NASAL BREATHE IS
INSTINCTIVE
GEORGE
CATLIN, 1870
THE UNION OF THE
FOODWAY AND THE AIRWAY
IN HUMANS HAS CAUSED
MANY ADAPTIVE PROBLEMS
THE USE OF THE MOUTH AS
AN EMERGENCY AIRWAY
OUTWEIGHS THE POSSIBLE
DANGERS OF CHOKING AND
INFECTION
WHAT IS THE ROLE OF THE
NOSE?
ITS FUNCTIONS ARE VITAL:
WARMING
HUMIDIFICATION
FILTERING
CLEANING OF AMBIENT
AIR INHALED INTO THE LUNGS
WHAT IS THE ROLE OF THE
NOSE?
THE NOSE IS A HIGHLY COMPLEX ORGAN,
INITIATING REFLEXES AFFECTING IT AND
THE REST OF THE BODY, SUCH AS:
• SNIFF REFLEX
• SNEEZE REFLEX
• AUTONOMIC AIRWAY/LUNG REFLEXES
• CARDIOVASCULAR REFLEXES
VASCULATURE OF THE NOSE IS
COMPLEX
SINUSOIDAL CAPACITANCE VESSELS
DISTENSIBLE VENULE CAPACITANCE VESSELS
ARTERIOVENOUS ANASTOMOSES
ARTERIOLES
CAPILLARIES
VENULESCELLS
SECRETORY TISSUE OF THE NOSE
• EPITHELIAL
• SUBMUCOSAL GLANDS
• SEROUS GLANDS
NASAL LINING
PSEUDOSTRATIFIED EPITHELIUM
•SEROUS, MUCOUS, SEROMUCOUS
GLANDS
•CAPACITANCE VESSELS
•SUBMUCOSAL LAYERS
•ARTERIOLES
ARTERIAL SYSTEM
DETERMINES BLOOD
FLOW
VENOUS SYSTEM
(CAPACITANCE
VESSELS)
DETERMINES NASAL
PATENCY
CAPACITANCE VESSELS
CONSTRICTION AND RELAXATION OF
VEINS DETERMINE NASAL PATENCY
CONTAIN SMOOTH MUSCLE
REGULATED BY AUTONOMIC
(SYMPATHETIC) NERVOUS SYSTEM
MOST DENSE IN THE INFERIOR AND
MIDDLE TURBINATES
LOSS OF SYMPATHETIC
TONE
& CHOLERGENIC
STIMULATION
CAUSE ARTERIAL DILATION AND ACTIVE SECRETION OF MUCOUS
…….RESULTING IN RUNNY
NOSE
SYMPATHETIC AND PARASYMPATHETIC
NERVES PLAY CRITICAL ROLES IN
REGULATING GLANDULAR, VASCULAR AND
OTHER PROCESSES IN AIRWAY MUCOSA
SYMPATHETIC NERVE STIMULATION CAUSES
CONSTRICTION OF THE RESISTANCE CELLS
PARASYMPATHETIC NERVE STIMULATION OF
THE NASAL VASCULATURE CAUSES DILATION
NASAL CONGESTION IS MORE A WITHDRAWAL OF
SYMPATHETIC DISCHARGE, THAN OVER
ACTIVITY OF THE PARASYMPATHETIC SYSTEM
ALLERGY – A HISTAMINIC
REACTION
CHARACTERIZED BY:
VASOMOTOR RHINITIS
MUCOSAL HYPEREMIA
ENGORGEMENT
HYPERRHINORHEA
OBSTRUCTED NASAL BREATHING
NASAL PATENCY IS
AFFECTED BY:
EXERCISE
DECREASES NASAL AIRFLOW RESISTANCE,
↑SYMPATHETIC DISCHARGE CONSTRICTS CAPACITANCE VESSELS
POSTURE
↑ NASAL RESISTANCE WHEN SUPINE
↑ NASAL RESISTANCE IN DEPENDENT NASAL PASSAGE IN LATERAL RECUMBENT
THE KEY TO
SUCCESSFUL NASAL
BREATHING IS
MAINTAINING A
CRITICAL BALANCE
NASAL CYCLE
80% – 20% SWITCH IN
NASAL PATENCY FROM ONE
NASAL CAVITY TO THE
OTHER EVERY 2 - 4 HOURS
OCCURS IN 60% - 70% OF ALL
HEALTHY INDIVIDUALS
Positional OSA
Unilateral blockage of right or left nasal
airway will have documentation of
apnic event difference during the nasal
cycle since more air can traverse the
side that is larger.
UPPER AIRWAY
RESISTANCE
2/3 NASAL RESISTANCE
1/3 PHARYNGEAL
RESISTANCE
NASAL VALVE
NARROWEST PART OF THE NASAL AIRWAY SYSTEM
CONTRIBUTES THE MOST
(OVER 50%) TO NASAL RESISTANCE
COTTLE’S
MANEUVER
COTTLE MANEUVER
NASAL VALVE IS THE NARROWEST SEGMENT OF NASAL CAVITY
CHEEK IS GENTLY PULLED LATERALLY WITH ONE TO TWO FINGERS
PATIENT ASKED IF INHALATION IS EASIER
IF AIRFLOW IS EASIER RESTRICTION, MAY BE AT NASAL VALVE
DONE IN SUCCESSION BY USE OF A NASAL DECONGESTANT, LOCALIZATION TO ORIGIN OF CONSTRICTION IS POSSIBLE
SNIFF TEST
SEAL YOUR LIPS, TAKE A DEEP
BREATH THROUGH YOUR NOSE
AS DEEP AND AS FAST AS YOU
CAN
NOSE BREATHER – THE NARES
FLARE
NASAL OBSTRUCTION – NARES
CONSTRICT
NARES
CONSTRICT
NARES FLARE
SNIFF TEST
TYPES OF AIRFLOW
FUNCTIONS OF NASAL
AIRWAY PASSAGES
1. TRANSPORT AIR TO & FROM LUNGS
2. OPTIMAL CONDITIONING INSPIRED AIR
a) HEATING
b) HUMIDIFICATION
c) FILTRATION
3. OLFACTION
4. RECAPTURE HEAT AND MOISTURE ON EXHALATION
THE LARGE, VASCULAR SURFACE AREA LINED WITH CILIATED
MUCOSA MAXIMIZES OLFACTION AND CONDITIONING
Humidification and
Dehumidification
During the intake of air it is humidified
to increase lung oxygen facilitation.
Upon exhalation the air is
dehumidified to keep water in our
cells. If this were not the case we
would dehydrate unless we
continually drank water.
TURBULENT AIRFLOW
BRINGS ABOUT:
1. BETTER WARMING
2. FILTRATION
3. HUMIDIFICATION
4. IRREGULAR FLOW
5. DIFFERING VELOCITIES
6. INCREASES WORK OF BREATHING
TURBULENT AIRFLOW
INCREASED BY:
1. PROJECTION OF INFERIOR
TUBINATES*
2. DOWNTURNED NOSTRILS
TWO DISTINCT
TYPES OF NOSES
LEPTORHINE PLATYRHINE
LEPTORRHINE NOSES, tall
& narrow
•DOWNWARD & INFERIOR DIRECTION OF NARES
•MAXIMIZE MUCOSAL SURFACE TO VOLUME
•FACILITATE HEAT AND MOISTURE EXCHANGE IN COLD, DRY ENVIRONMENTS
•AIRFLOW MUST NEGOTIATE 90⁰ BEND FROM EXTERNAL NARES TO HORIZONTAL CHAMBER
• WELL DEVELOPED NASAL VALVE
•GREATER PROJECTION OF THE NOSE, HIGH NASAL SILL AND PROJECTING TURBINATES ENHANCE TURBULENT AIRFLOW
PLATYRHINE NOSES, short
& broad
LOWER SURFACE AREA TO VOLUME RATIO
LESS EFFICIENT HEAT RECAPTURE
NARES MORE ANTERIORLY DIRECCTED
POOR OR NO DEVELOPMENT OF NASAL VALVE
NO OR POORLY DEVELOPED NASAL SILL
LITTLE OR SMALL PROJECTION OF TURBINATES
ECOGEOGRAPHICALLY WARM WEATHER SETTLER
LAMINAR AIRFLOW
IN HUMAN
NOSES THERE
IS LESS
LAMINAR
AIRFLOW IN
PLATYRHINES
THAN
LEPTORHINES
Cosmetic Surgery
He couldn’t breath through his small nose, became hypercapnic and died
THE AIRFLOW IN THE BEFORE AND AFTER NOSES CANNOT BE THE SAME
90⁰90⁰
• TWO 90⁰ TURNS IN
AIR FLOW
•NARROWEST OPENING
AT NARES
•VARYING CROSS-
SECTIONAL AREA
THROUGHOUT AIRWAY
•VARYING
OBSTRUCTIONS IN
AIRWAY
•VARYING THICKNESS
OF MUCOSAL WALLS
LAMINAR AIRFLOW
CANNOT OCCUR IN
BOTH THE BEFORE
AND AFTER
SURGICALLY ALTERED
NOSES
BERNOULLI’S
PRINCIPAL
DECREASE IN SIZE OF THE
LUMEN CAUSES AN
INCREASE IN VELOCITY OF
AIR, RESULTING IN A
DECREASE IN PRESSURE,
SUCKING IN THE
COMPLIANT WALLS AND
POTENTIATING CLOSURE
The more obstructions, the
more turbulence and
greater suction on the walls
POISSEUILLE’S LAW
IN AN AIRWAY WITH A DIMINUTIVE LUMEN,
INCREASES IN RADIUS SIZE CAUSE EXPONENTIAL
CHANGES IN AIRFLOW
BERNOULLI &
POISSEUILLE
INCREASE THE SIZE OF THE
AIRWAY
REDUCE THE TURBULENCE
ENHANCES AIRFLOW
AND
PREVENTS COLLAPSE OF AIRWAY
THE CONTRIBUTION OF THE
NOSE TO AIR FLOW IS BASED
ON THE
BERNOULLI & POISSEUILE
EFFECTS
NASAL AIRFLOW AFFECTS
COLLAPSIBILITY OF THE ORAL AIRWAY
Sleep complaints portend worse
outcomes among those with chronic
pain. Compared with patients who have
no sleep complaints, patients with
chronic pain and insomnia report poorer
quality of life indices and have
increased health care utilization
Association of Obstructive Sleep Apnea
and Chronic Pain May 2013
The End
Thank you for not falling asleep during
my lecture.
Dr. Richard Klein