t age 48, Bill sometimes wondered if he was going to die early, or atleast have to give up work. His 20-year-plus snoring problem haddeteriorated into sleep apnoea—where his dreadful snoring wasnow interrupted by worrying silences (where he had stopped

breathing), then gasping and choking episodes as he resumed breathing. Sometimes Bill woke himself up with particularly loud snoring or the jerking

of his body as he fought for his breathing to resume. His days werepunctuated by nausea, diarrhoea and debilitating fatigue. Fainting was thefinal straw, and Bill went to see his doctor. An overnight "sleep study" showedthat Bill had obstructive sleep apnoea, a condition where breathing stopsintermittently throughout the night due to obstruction in the upper airway.

He was advised to have laser surgery to remove a portion of his soft palate.The other option put to Bill was to use a CPAP (continuous positive airwaypressure) machine—an air pump attached to a face mask. However, Bill wasnot guaranteed that surgery was a permanent solution nor that it would solvehis particular problem, and he learned that some spouses of CPAP wearersfind the appliance very intrusive. Difficult decisions, but something had to bedone. Snoring and sleep apnoea are hazardous to health and need to betaken seriously. I'll talk more about Bill a little later.

Snoring and Sleep Apnoea ExplainedSnoring is the noise created by turbulence and vibration of the tissues

lining the throat as air passes through to the lungs. Snoring is far more thanjust a bad noise: it increases the risk of high blood pressure, heart attack anderectile dysfunction, and can put stress on a relationship. There is a highincidence of chronic snoring among men who suffer strokes. Furthermore,worsening snoring is a risk factor for developing the much more seriouscondition of sleep apnoea (or apnea).

Sleep apnoea is where breathing stops for intervals of 10 seconds or more,repetitively throughout the night, causing a significant drop in the amount ofoxygen in the blood. With obstructive sleep apnoea, the walls of the throatmay "collapse" inwards or part of the soft palate or the tongue may be drawnback into the throat, obstructing air flow. As well as causing devastatingdaytime sleepiness, untreated sleep apnoea puts you at greater risk for highblood pressure, angina, irregular heart rhythms, heart attack, depression,obesity, diabetes and cancer. In children, it is associated with retardedgrowth as well as learning and behavioural problems.

The burden of sleep-breathing disorders rests heavily not only on thesufferer but also their bed partner, their employer and the health system. Thebed partner is not getting a good night's sleep—and maybe the neighboursaren't, either.

Road users are at risk. People with sleep apnoea are said to be two to seven

Sleep disorders area modern epidemic,

but medicalinterventions aren’talways successful or

well tolerated. The good news is

that there aresimple techniqueswhich can be usedto restore correct

breathing andimprove sleep within

only a few days.

APRIL – MAY 2014 www.nexusmagazine.com NEXUS • 33

SSNORINGNORING, S, SLEEPLEEP AAPNOEAPNOEA

ANDAND BBREATHINGREATHING RRETRAININGETRAINING

A

by Tess Graham © 2014

BreatheAbility InternationalPost Office Box 4393

Manuka, ACT 2603, AustraliaTelephone: +61 (0)2 8188 1343

Email: admin@BreatheAbility.comhttp://BreatheAbility.com

34 • NEXUS www.nexusmagazine.com APRIL – MAY 2014

times more likely to have a road accident.1 They alsohave an increased incidence of workplace accidents.

The direct and flow-on costs to business and thehealth care system are enormous. Sleep disorders costthe Australian economy more than $10 million eachyear2, and the number of people being diagnosed eachyear continues to grow. These costs are skyrocketing asthe incidence of snoring and sleep apnoea increases.

Medical Treatments and Appliances It will come as no surprise that with these statistics

there is a thriving industry in diagnostic "sleep clinics"and in manufacturing and selling products to treat theproblems. New sleep clinics are popping up in suburbanareas, and nearby are shops with sleep apnoea suppliesincluding a large array of machines and masks fromwhich to choose. These places did not even exist 30years ago.

Oral appliances (dental splints) are supplied by dentalsurgeries, and all manner of products, devices andaccessories are sold in pharmacies and on the Internet,all promising relief. This is relief, not cure, as it isacknowledged that in most cases the underlyingproblem persists and lifetime treatment is required.

When we look at the medically approved treatmentsfor snoring and sleep apnoea, we see that for the mostpart they have been designed to create larger or morerigid (more open) breathing passages to allow freer airflow to the lungs. Treatments offered include:

• Medication to reduce nasal inflammation andcongestion.

• Surgical procedures such as removing tonsils andadenoids, trimming "excess tissue" from the soft palate,opening or "reboring" nasal passages, reducing the sizeof the tongue or anchoring it in a more forward position,and remodelling or repositioning the jaw.

• Oral appliances such as mandibular advancementsplints and tongue retainers which are worn during sleep

to hold the jaw and tongue more forward to help braceopen the airway at the back of the throat.

• CPAP, an apparatus used during sleep and consistingof an air-pump machine, tubing and face or nose maskwhich delivers positive air pressure to brace the airwayopen and prevent obstructive sleep apnoea.

CPAP is the "gold standard" treatment for sleepapnoea. However, as a gold-standard treatment it has asignificant shortcoming. While it works extremely well toreduce or eliminate apnoea episodes and improve sleepquality, studies show that only 30 to 60 per cent ofpeople for whom CPAP is the recommended optioncomplied with the treatment.6

Not surprisingly, many people find CPAP unacceptableor intolerable. This can be because of claustrophobia, orbecause they've started a new relationship, or because ofdifficulty in finding a comfortable mask or machinedespite the wide variety available. The use of CPAP on anightly basis for the rest of your life can be a dauntingprospect, and many reject it.

The success rate of the surgical options varies with thedifferent procedures, but estimates suggest that it isgenerally not more than 50 per cent, especially in thelong term. The oral appliances can be very helpful forsnorers and people with less severe apnoea, but theyalso are not always successful or tolerable and are notrecommended in cases of severe sleep apnoea.

When CPAP or an oral appliance suits the patient andis worn all night, the night-time symptoms of snoringand sleep apnoea can be eliminated or greatly reducedand energy levels are much better during the day. It canbe a remarkable turnaround in health and well-being formany people. However, these appliances only work ifthey are worn every night for most of the night. There isno carry-over improvement in the underlying snoring orapnoea problem.

What’s Going On In Our Bedrooms? Lying there at night, trying to ignore the noise of a

snoring bed partner, have you ever wondered why peoplesnore? If you've had the altogether scary experience oflying next to a loved one who stops breathing and then

CPAP full face mask

SOME STATISTICS • It’s estimated that around 40 per cent of the adultpopulation snores at least occasionally, with the figurerising to around 60 per cent in the over 40s. • While the incidence of snoring is greater in men andthe middle-aged, more than 30 per cent of middle-agedwomen are said to snore habitually. • A study of primary school children in Perth, WesternAustralia, found that 15.2 per cent were habitualsnorers.3

• In 2010, an estimated 4.7 per cent of the Australianpopulation over 20 years of age had obstructive sleepapnoea (OSA) though this may be underestimated asOSA is considered to be significantly underdiagnosed.4

• The US National Sleep Foundation estimates that morethan 18 million American adults have sleep apnoea andthat a minimum prevalence of 2 to 3 per cent exists inchildren.5

APRIL – MAY 2014 www.nexusmagazine.com NEXUS • 35

jerks their body and makes choking sounds whilestruggling to get a breath in, have you ever wonderedwhy their breathing stops or when they will startbreathing again?

The traditional medical viewpoint sees snoring andsleep apnoea connected with the breathing passagesbeing or becoming too narrow to allow easy, quiet andcontinuous breathing during sleep. Contributing factorsare seen to include nasal congestion, a deviated nasalseptum, enlarged tonsils and adenoids, excess fataround the neck, a small or retracted jaw, a narrow upperpalate or an overly large tongue. However, this"explanation", while indeed including factors whichcontribute to airway narrowing or obstruction, fails toexplain how snoring and apnoea can occur in peoplewith none of these factors beingpresent or can be absent despiteseveral of them being present. Also, itdoes not explain why sleep apnoeaoften develops in people many yearsafter they have developed their "risky"adult facial features and body type.

Consider this: unless you have hadfacial injuries, you likely have hadmuch the same-shaped nose andupper palate and the same-sized jawand tongue all your adult life. If youare 45 now and chronically snore andhave sleep apnoea, but did not at age30, it is unlikely that your tonguehas grown significantly larger,your septum has become moredeviated or your jaw hasnarrowed.

Something has changedsubstantially, but what is it?Could there possibly be anotherway of looking at this problemwhich reveals a more fundamentalsolution?

What’s Been Missed? The first thing you need to know

is that snoring and sleep apnoea do not occur in peoplewith a normal breathing pattern. People who snore andhave sleep apnoea do not breathe correctly; there are noexceptions.

While snoring and sleep apnoea can certainly be madeworse by anatomical factors and things like drinking toomuch alcohol or having a cold, a fundamentalcontributing factor in both is a high inspiratory airflow rate:high-volume, high-speed breathing—that is, inhaling anexcessive amount of air and inhaling it rapidly.

Most often, snorers are unaware of their heavy airusage. In the daytime, they can be so used to it that theydon't notice their mouth-breathing, somewhat heavierbreathing, upper-chest breathing or their intermittent

deep breaths, sighs or yawns. These are all indicators ofan overbreathing pattern. When you're lying down andasleep, however, overbreathing and its effects may bevery noticeable to an observer.

Anyone who has slept next to a heavy snorer willidentify with this high "drive to breathe". One womandescribed her partner's snoring this way: "He breathestwo breaths for my one. When he breathes in, it's likehe's sucking the paint off the walls; when he breathesout, I feel I have to hold on to the edge of the bed so hedoesn't blow me out."

When you breathe in too quickly and/or too heavily, thesoft tissues lining your airway can become dehydrated,swollen and congested, narrowing your airway. Duringsleep, when your throat muscles are more relaxed, these

tissues can vibrate and create thesnoring noise. Obstructive sleep apnoea is like sucking

too hard on a straw. Breathe in quicklyor heavily enough and you may suckthe walls of your throat closertogether, or suck your tongue or uvulabackwards, and limit or completelyobstruct the flow of air to your lungsfor a period of time. These effects arerelated to laws of physics: the Venturiand Bernoulli effects.

Research has shown that men withsleep apnoea breathe an average of 15

litres of air each minute.7 This isthree times as much as a healthybreather does.

Now a hearty snore and asuction force sufficient toobstruct your throat are not likelyto happen when you breathenormally—which is to breathe inand out, silently, slowly, gently,about 10 times a minute, 500millilitres per breath, a total ofaround five litres of air eachminute. This breathing is calledphysiologically normal breathing.8

As well as its mechanical effects on the airway(turbulence, vibration, suction), described above, high-volume breathing creates imbalance in the levels ofcarbon dioxide and oxygen in the blood, affecting bloodchemistry. If the level of carbon dioxide drops sharply,the signal from the brain to the diaphragm may fail andbreathing may cease temporarily. This is called centralsleep apnoea.

When imbalance in carbon dioxide is maintained overa critical period of time, the carbon dioxide "set point" ofthe breathing receptors in the brain which drive yourbreathing become altered from the optimum. From thenon, you can end up unconsciously breathing at a ratethat is detrimental to body function and chemical

The first thing youneed to know isthat snoring andsleep apnoea do

not occur inpeople with a

normal breathingpattern. Peoplewho snore and

have sleep apnoeado not breathecorrectly; there

are no exceptions.

processes and results in reduced oxygenation of cells,tissues and organs throughout the body (the Bohreffect).

Breathing is a critically important body function. It isthe first thing we do in life, and the last. Many peopleare getting it wrong over 20,000 times a day.

It is very likely that a person's breathing pattern haschanged significantly over the period of time in whichthey developed a heavy snoring and apnoea problem.However, someone with snoring and sleep apnoea isunlikely to know this, and checking a person's baselinebreathing pattern is not part of standard medicaldiagnosis. Nor do the commonly used treatments forsnoring and sleep apnoea seek to address thefundamental disturbance in breathing pattern—theabnormal way of breathing. People are often steeredtowards surgical, pharmaceutical or appliance-basedinterventions without considering what they can dothemselves to improve their breathing habits. (This isnot unlike obese patients with poor eating habits havinggastric band surgery without first being advised to try toimprove their diet.)

Overbreathing: Overlooked!Snoring and sleep apnoea are fundamentally problems

with the way you breathe—day and night. Overbreathing is a prime contributory factor in snoring

and sleep apnoea—and thankfully it's one that you can

do something about.One of the most comprehensive

discussions on overbreathing orhyperventilation is the aptly titled paperby Dr Gregory Magarian et al.:"Hyperventilation syndrome: Adiagnosis begging for recognition"(1983).9 He commented that whileacute hyperventilation (as in a "panicattack") is fairly easy to see, thechronic form often goesunrecognised.

Medical scientist and physicianProfessor Konstantin Buteyko coinedthe term hidden hyperventilationbecause of the often subtlepresentation of its chronic form. Hisexhaustive research spanning severaldecades from the 1950s showedchronic hyperventilation to be veryprevalent in the general population.10

Chest physician Dr Claude Lumpublished extensively on thehyperventilation syndrome. In hisarticle "Hyperventilation: the tip andthe iceberg" (1975)11 he had this tosay. "The many organs involved areoften reflected in the number ofspecialists to whom the patient gets

referred, and my colleagues have variously dubbed thisthe 'multiple doctor' or the 'fat folder syndrome'. Indeedthe thickness of the case file is often an importantdiagnostic clue."

The consequences of overbreathing day after day arefar reaching. The body struggles and tires as it tries tomaintain equilibrium.

Unfortunately, diagnosis of this extremely commondisorder does not appear to have improved at all sinceMagarian, Buteyko and Lum published their findings.

Yet the incidence of overbreathing is even greater now.More and more people are breathing too rapidly or aresnoring or mouth-breathing—and these include largenumbers of children. Rarely are parents and teachersaware of the consequences of this. Parents may have tocope with constant mucus conditions and tired children,teachers with behavioural and learning issues, dentistswith tooth decay, orthodontists with the narrow upperpalates and crowded and crooked teeth which areconsequences of mouth-breathing.

Breathing Retraining It was a stroke of good luck for Bill (whom we met at

the beginning of this article) that, while faced with thedifficult choice between throat surgery and CPAP, heheard about a breathing retraining course. The conceptmade sense to him—after all, for over two decades thereobviously had been something wrong with the way he

36 • NEXUS www.nexusmagazine.com APRIL – MAY 2014

FAULTY-BREATHING QUIZ

[ ] Do you snore?

[ ] Do you ever wake up gasping or choking and coughing?

[ ] Is your breathing audible day or night?

[ ] Is your breathing heavy or laboured?

[ ] Are you breathless at any time?

[ ] Do you often feel “spacey” or dizzy?

[ ] Do you mouth-breathe?

[ ] Do you breathe with your upper chest?

[ ] Do you breathe more than 14 times a minute?

[ ] Is your breathing irregular or erratic?

[ ] Do you breath-hold in the day or night?

[ ] Do you have panic attacks?

[ ] Do you have a persistent or irritable cough?

[ ] Is your nose often stuffy or congested?

[ ] Do you feel like you can’t get enough air when you nose-breathe?

[ ] Do you sigh, yawn or clear your throat often?

If you have answered YES to one or more of these, then you likely have adisordered breathing pattern and may benefit from breathing retraining.

APRIL – MAY 2014 www.nexusmagazine.com NEXUS • 37

was breathing! From the second day of the breathingcourse, he noticed an improvement in his sleep. By theend of that week, his concentration and stamina werebetter and, according to his wife, he was no longersnoring. Some months later, he had a repeat sleep studydone—and there was no evidence of sleep apnoea. Bytaking responsibility for the way he breathed, Bill had ineffect "fixed" himself.

Breathing training/retraining is the specific disciplinein which the primary goal is to normalise each aspect ofthe breathing pattern (rate, rhythm, volume, use of thenose, use of the diaphragm) for all situations (awake,asleep, at rest, during eating, speech and exercise).12

The process involves identifying incorrect breathinghabits, undoing them and replacing them with thecorrect ones. Step by step, you replace faulty breathingwith silent, efficient, gentle diaphragm-breathing. Itworks because while breathing is automatic, you canalso consciously vary it.

Think of your brain as having amanual override and resetbutton. You practise breathingcorrectly during the day toretrain (i.e., reprogram or reset)the brain's "drive to breathe"centre to operate at the correctlevel at rest, when exercisingand while sleeping. When it isreset, quieter, softer, moreregular breathing is maintainedday and night.

Assessing The Breathing Pattern There are some simple checks and observations that

can be made to alert to the presence of overbreathingand other dysfunctions.

Breathing educators assess their clients by observingthe rate, rhythm, volume, mode and mechanics ofbreathing, and through questionnaires. They also usebreath-hold tests or capnometry. (Capnometry monitorsthe partial pressure of carbon dioxide in expired air.)

People with asthma, anxiety or sleep apnoea often tickoff more than 20 different symptoms of overbreathing asthey fill in the form on their first visit to a breathingeducator. They can often be observed overbreathingwhile they complete the questionnaire!

Janelle, aged 42, came for breathing retraining becauseof her heavy snoring and sleep apnoea. She also hadrestless legs, dizziness, chest pains, palpitations, anxiety,lots of mucus and debilitating fatigue. As she put it, shehad already "been through the mill", having undergone asleep study, an operation on her nose and an exercisestress test with her cardiologist. She was prescribedvarious medications. She had tried but could not adjustto sleeping with a CPAP machine; she feltclaustrophobic.

Janelle's breathing was not fast but was audible, very

heavy and from the upper chest. She sighed frequently.On her pre-training questionnaire she marked off 54different symptoms of overbreathing, ranking many ofthem moderate to severe. Janelle was amazed to find outthat providing information about what was happening inthe day and how she breathed when awake was just asimportant to the breathing educator as her night-timesymptoms. For Janelle, eight days into breathingretraining she was sleeping well. Her husband said thatshe no longer snored. Her chest pain and palpitationshad ceased. She was calm and had more energy.

The Training Process A typical breathing training program involves an initial

consultation with a breathing educator, then a structuredprogram of five to eight 90-minute sessions (60-minutesessions for children).

Clients should practise the exercises and techniqueson a daily basis, formally andinformally, until their breathingpattern is normal and stable oruntil they reach the best pointthey are capable of within theconfines of their condition.They can then taper down theexercises to maintain theimprovements.

It really is that simple. Thebenefits are immediate, andmost people comment that theyhave had their best sleep indecades within just a few days

of starting the process. Clients are advised that changes in prescribed

medication and treatments must be undertaken only inconsultation with their doctor. A follow-up sleep study isrecommended for clients with sleep-breathing disorders.

Scientific Evidence Breathing retraining is a science-based process, and

peer-reviewed studies show its effectiveness innormalising breathing patterns.13–17

The most researched and best-known form ofbreathing retraining is the Buteyko Method of BreathingReconditioning, developed by and named after Ukrainiandoctor Konstantin Buteyko.

While breathing retraining has been acknowledged asan effective and safe adjunct therapy for asthma by theUS government's Agency for Healthcare Research andQuality and by the British Thoracic Society,unfortunately it is not as widely known as a managementoption for sleep-breathing disorders.

However, there is a large body of anecdotal evidencesupporting its effectiveness. In 2010, the ButeykoInstitute of Breathing & Health conducted aretrospective survey among its members. Practitionerswho participated had collectively taught over 11,000

The benefits are immediate,and most people commentthat they have had theirbest sleep in decades

within just a few days ofstarting the process.

38 • NEXUS www.nexusmagazine.com APRIL – MAY 2014

clients with sleep apnoea. A majority of practitioners (73per cent) estimated that over 95 per cent of clients hadimproved their sleep after completing a course inbreathing retraining.18

The simplest things in life are often the best: changingthe way you breathe has to beat having a machine do itfor you.

What Makes You Breathe Incorrectly?Breathing is influenced by many factors, including

stress, training in breathing, habit, posture and diet. For those who have sleep apnoea, it is most likely that

they breathe more heavily and/or more quickly now thanthey used to do. They may have developed a habit ofmouth-breathing without noticing it, an irritable drycough, habitual sighing or throat clearing, or breathingmore quickly and with the upper chest because of aslumped seated posture or persistent anxiety.

Getting Help For Your BreathingThe number of breathing educators worldwide is

comparatively small, but is growing due to theconsistently profound results achieved with breathingretraining. In Australia, there are breathing educators inmost capital cities and in some regional centres.

Snoring and sleep apnoea can have devastating healthand social consequences. They need to be adequatelyaddressed by one means or another. Breathingretraining is a safe, natural and commonsense approachto what is, after all, a breathing problem.

It should be part of a mainstream approach. At thevery least, breathing retraining should be offered as anoption to people with sleep-breathing disorders whohave found surgical or appliance-based approachesunsuccessful or unacceptable.

It is hoped that awareness of poor breathing habitsand of the benefits of breathing retraining will continueto grow in the community and will lead toimplementation of prevention strategies within ourprimary health care system.

Breathing retraining offers a wonderful opportunity toempower yourself to improve your health and quality oflife. It is never too late to change. An 80-year-oldactually volunteered herself for a television news storybecause she wanted to let other people know that "youcan teach an old dog new tricks".

There is nothing more fundamental to health than getting yourbreathing right. ∞

About the Author: Tess Graham is a physiotherapist and breathing educator.She has extensive clinical and research experience inbreathing retraining and has worked exclusively in this fieldfor over 20 years. Two of her three children had asthma,which was continuing to worsen despite being managed byconventional medical treatments. The turnaround forthem came when they took part in a breathing retrainingcourse. This was also the turning point of Tess’s career.She undertook considerable research into breathing,including training in the Buteyko Breathing Method. In1993 in Canberra, she established Australia’s first dedicatedbreathing clinic. Tess has now taught breathing retrainingprograms to over 5,500 people and lectured throughoutAustralia and overseas. She is the author of Relief fromSnoring and Sleep Apnoea: A step-by-step guide to restfulsleep and better health through changing the way youbreathe (Viking/Penguin, 2012; reviewed in NEXUS 21/02).

Tess Graham is director of BreatheAbility International.She can be contacted by telephone at +61 (0)2 8188 1343,by email at admin@BreatheAbility.com or via theBreatheAbility website, http://BreatheAbility.com.

Endnotes1. Austroads Ltd, "Assessing Fitness to Drive", March2012 (4th edition), p. 105, http://tinyurl.com/m3rqnv8,accessed 19 March 2012 2. Deloitte Access Economics, "Re-awakening Australia:The economic cost of sleep disorders in Australia, 2010",commissioned by the Sleep Health Foundation,published October 2011, http://tinyurl.com/l9pzwob3. Zhang, G., Spickett, J., Rumchev, K., Lee, A.H., Stick, S.,"Snoring in primary school children and domesticenvironment: A Perth school based study", Respir. Res.2004 Nov 4; 5(1):19, published online 4 November 2004,doi: 10.1186/1465-9921-5-19, http://tinyurl.com/ko4kkmu4. Deloitte, ibid.

Continued on page 83

Five Tips for Better Breathing,Health and Sleep

1. Be aware of your breathing. Know thatphysiologically normal breathing is nasal,

silent, slow, soft, smooth breathing.

2. Breathe through your nose whenever itis comfortable to do so.

3. Breathe more gently. If your nose isblocked or you are uncomfortable

breathing through it, then try to breathemore gently through your mouth.

4. Sit more upright. When you slouch,you are more likely to breathe faster andwith the upper chest, which is tiring and

makes you feel stressed.

5. See a breathing educator for additional help.