Posted by on Mar 1, 2021 in Uncategorized |

Breathe Well to Sleep Well

 

Breathing correctly during sleep is crucially important. However, dysfunctional breathing is usually an unrecognised and unaddressed factor, in regard to obtaining quality sleep. Most people have little awareness of how they breathe when they’re awake; let alone when they’re asleep. Whilst we have no conscious control over how we breathe during sleep, we can exercise conscious control over how we breathe when we’re awake. Improper breathing during sleep is a factor that can deprive many people of quality sleep.

The way an individual breathes during sleep is to a considerable extent determined by the way they breathe during their waking hours. That said, an individual’s breathing can get considerably worse when they’re asleep. People who snore and those who have obstructive sleep apnoea (see later) invariably breathe incorrectly during the day, in addition to during sleep.

As breathing is the first and last behaviour we engage in, in life, and we do it 24/7, we might as well do it right. By doing so, we afford it the importance and attention it deserves in our pursuit of good health. How we breathe is not only very important during our waking hours, it’s also very important during the time we are asleep.

Dysfunctional breathing

In that breathing is behaviour that can be changed; an individual’s past experience can result in unconsciously learning to breathe in a dysfunctional way. The unconscious learning of bad breathing habits can adversely affect health. This includes having a detrimental effect on sleep. Etiological (causative) and maintaining factors that may play a role in the unconscious learning of dysfunctional breathing habits might include the following:

  • Habitual mouth breathing
  • Poor posture
  • Chest and nose conditions that affect the airways
  • Chronic negative emotions such as anxiety, fear, panic disorder, depression, anger, and sustained boredom
  • Sleep deprivation
  • Alcohol, nicotine, caffeine, or recreational drug use
  • Taking big breaths to “relax”

In the vast majority of cases, faulty breathing habits are not identified or seriously addressed. However, research has demonstrated that through changing breathing habits/behaviours, you can reprogram the respiratory centre in the brain. This retraining and consequent reprogramming is possible because, although we usually breathe automatically without thinking about it, we can also exercise conscious control to change it for better health.

If someone routinely snores or has sleep apnoea, then they definitely have a disordered breathing pattern. Whilst this is generally more obvious (to an observer) when the individual is asleep, they also usually show signs when they’re awake e.g. mouth breathing, upper chest breathing, sighing, heavy, irregular and fast breathing, or gasping inhales while talking.

Breathing Retraining

The goal of breathing retraining (sometimes called breathing re-education) is to physiologically normalise (or as close to as possible) an individual’s breathing pattern (rhythm, rate, volume, mechanics, use of nose) for all situations i.e. awake, asleep, at rest, during exercise, during eating, and while talking.

The use of the nose for breathing, as opposed to the mouth, is very important. The nose was created for breathing (both in and out) and the mouth was created for eating, drinking, talking, singing, etc. Nose breathing has many health benefits and chronic mouth breathing has numerous possible adverse consequences. If you would like to learn more about this, you can access my journal article titled ‘The health benefits of nose breathing’ via the link below.

https://105b31079a1ba381f52e-ac2ec5114feb632a1114f20df0e72453.ssl.cf2.rackcdn.com/Page/56d987e0-d130-48cf-97f0-08840ad284e6/the-health-benefits-of-nose-breathing.pdf

Practising ‘functional’ breathing and doing breathing exercises during the day will result in improvements in daytime breathing patterns and this will help prevent or ameliorate disordered breathing during sleep. These practices can reset the respiratory centre (or ‘drive to breathe’ centre) in the brain so that you will breathe more correctly during sleep e.g. softer, more quietly, and more regularly.

Breathing expert Dr. Rosalba Courtney has defined functional breathing as breathing that “most efficiently performs its various functions taking into account the circumstances and condition of the patient.” She created the acronym EAARS as one way to think about whether an individual’s breathing is functional.

EAARS stands for – Efficient, Adaptive, Appropriate, Responsive and Supportive of heath

Assessment, education and training, are all aspects of the breathing retraining process. The method of breathing and the exercises taught are tailored to the individual client so that they are not too physically demanding. ‘Informal practice’ i.e. incorporating better breathing into normal daily activities, is a very important part of the breathing retraining process.

The extent and speed of breathing improvement will vary from person to person. The factors that will affect this are: the extent of breathing disturbance, the individual’s motivation and commitment, underlying health conditions, and the level of self awareness a client has in relation to their breathing.

Normal, healthy breathing during sleep should be similar to normal, healthy daytime/wake time breathing i.e. silent or very quiet, and in and out through the nose. Although the pattern changes a little depending on the sleep stage; in normal sleep, it is generally smooth and gentle. During restorative sleep, the body is very relaxed and the volume of air being inhaled and exhaled is naturally lower than during waking hours.

Learning to control your breathing, through breathing re-training can make a big difference in both managing and helping to prevent insomnia, and the anxiety that’s often associated with it. Controlled breathing is very calming. It’s a natural sedative. It enhances the autonomic nervous system’s parasympathetic state – the resting state. It’s a wonderful tool to calm your mind, calm your nervous system, calm your body and get off to sleep.

My approach to breathing retraining

In relation to breathing retraining, my own approach is mainly influenced by the Buteyko Breathing Method. I also draw on aspects of ancient Yogic Breathing (Pranayama), Mindfulness of Breathing (Anapanasati), Slow Paced Breathing, and Resonant Frequency Breathing.

Buteyko Breathing Method

The Buteyko method is the breathing retraining method that has elicited the most research interest in recent years. The method was developed in the early 1950′s by an eminent Ukrainian born medical doctor and scientist called Professor Konstantin Pavlovich Buteyko. Professor Buteyko lived and worked in Moscow.

The Buteyko breathing method encourages breathing control as part of daily life. In the early stage of breathing retraining, patients are taught a structured daily routine of breathing exercises. The main breath control technique of the Buteyko Method is reduced-volume breathing. It is particularly important that patients relax during reduced volume breathing to counteract their body’s natural tendency to increase respiration as a response to decreased tidal volume (i.e. the volume of air that is inspired or expired in a single breath during regular breathing).

According to Dr. Rosalba Courtney, the mechanisms of the Buteyko method are likely to be more complex and to include psychophysiological, neurological and biomechanical mechanisms, in addition to biochemical mechanisms centred on carbon dioxide, which are central to the theory that Professor Buteyko proposed in the early 1950s.

Essentially, the Buteyko Method is a method for retraining and ‘normalising’ an abnormal ‘automatic’ breathing pattern. Its correct and disciplined implementation can result in improvements in a wide variety of conditions such conditions as insomnia, snoring, obstructive sleep apnoea, anxiety disorders, asthma, COPD (chronic obstructive pulmonary disease), sinusitis, hay fever (allergic rhinitis), non-allergic rhinitis, rhinosinusitus, blocked nose, allergies, bronchitis, and bronchiectasis.

The Buteyko method of breathing retraining helps normalise both daytime and night-time/sleep-time breathing. Over-breathing stimulates the sympathetic branch of the autonomic nervous system and places the body on alert mode. Insomnia sufferers typically exist in a permanent state of sympathetic stimulation/arousal and while this may go unnoticed during daylight hours, the resulting busy, chattering mind limits the chances of quality sleep. Learning and practising the Buteyko method can help to normalise breathing pattern, putting the body in a naturally calmer state for optimal sleep.

Very briefly, the Buteyko Method consists of the following:

  • Nasal breathing – people are taught how to stop mouth breathing and breathe through their nose.
  • Breathing control – people are taught how to reduce the volume of breathing while relaxing and mindfully accepting slight breathlessness. This can correct or reduce hyperventilation and increase tolerance for breathlessness.
  • Breath-holding techniques – Buteyko style breath-holds help to clear the nose, ease tight chests and clear the airways.

Ancient Yogic breathing

One of the five principles of Yoga is proper breathing. Yogic breathing is called ‘pranayama.’ Pranayama means “to control the breath” or “mastering the life force.” According to the ancient philosophy of yoga, breathing controls the flow of prana, the cosmic life force in the body. Also, according to ancient texts, the nose is the proper instrument for breathing rather than the mouth and breathing should be abdominal (diaphragmatic) breathing in a slow and rhythmic pattern, rather than chest breathing. The ancient yogis and yoginis believed that this form of breathing facilitates the flow of prana. Unfortunately, many ‘modern’ books on yoga do not mention the importance of nose breathing. However, in a book co-authored by Dr. Georg Feuerstein, an internationally renowned Yoga researcher, it states:

“No matter what anybody else tells you, yogic breathing typically occurs through the nose, during both inhalation and exhalation. For traditional yogis and yoginis, the mouth is meant for eating and the nose for breathing.”

Having said this, the book notes that a few classical techniques for breath control require you to breathe through the mouth. Adriana Sobi-Wilderman, the author of a book on Yoga breathing techniques, and Bellur Krishnamachar Sundararaja Iyengar, better known as B.K.S. Iyengar have also emphasized the importance of nasal breathing. Bellur was the founder of the style of yoga known as “Iyengar Yoga.” He was considered one of the foremost yoga teachers in the world.

Original yoga manuscripts, for example, Hatha Yoga Pradipika, Gheranda Samhita and Shiva Samhita also advocate restraining, keeping in, calming, and holding the breath. They do not make any mention of taking big breaths. It’s interesting to note that all of these fundamental principles of ancient Yogic breathing (including nasal breathing) are incorporated in the Buteyko Breathing Method,

If you would like to learn more about Yogic breathing, the link below enables you to access an article titled ‘Yogic Breathing: Ancient and Modern’ that I had published in Contentment (American institute of Stress). It’s on pages 26 to 31 of the publication.

Contentment June 2018.pdf (stress.org)

Mindfulness of Breathing (Anapanasati)

Based on my knowledge of mindfulness, it’s my view, bearing in mind the high prevalence of unhealthy mouth breathing in modern society, that modern mindfulness teachers should act on the ancient wisdom of Anapanasati (mindfulness of breathing) and instruct individuals to breathe in and out through their nose during mindfulness of breathing practice, and indeed, in everyday life.

Over the years, I’ve completed a number of mindfulness courses. During these courses I was somewhat surprised to find that when mindfulness of breathing was explained, there was no mention of the importance of breathing in and out through the nose. The participants in these courses were instructed to focus on their breathing, without trying to change it in any way. In other words, anyone who was breathing in an unhealthy way e.g. mouth breathing, was effectively being instructed to continue doing so.

Subsequent to taking these courses, I bought many fairly recently published books on mindfulness, written by individuals regarded internationally as experts in the field. Again, I was somewhat surprised to observe that the importance of nose breathing (both in an out) was not mentioned in any way in the overwhelming majority of these books. Only one of the books made a specific reference to nose breathing (the touch of air at the nostrils) in its instructions for the mindfulness of breathing exercise. This book is titled ‘The Art and Science of Mindfulness’ by Professor Shauna Shapiro and Professor Linda Carlson. It states:

“Focus your attention on the breath as a primary object of attention, feeling the breathing in and breathing out, the rise and fall of the abdomen, the touch of air at the nostrils.” (p. 13)

For the many people who are chest breathers and mouth breathers, following the above instruction would actually require them to change their breathing. You will note that the quotation above also specifically mentions abdominal (diaphragmatic) breathing in referring to the rise and fall of the abdomen.

In 2016, I decided to e-mail five individuals who were recognised as world leading experts in mindfulness, to ask them why the importance of nasal breathing wasn’t being highlighted in modern mindfulness teaching. I received a reply from only three of them. One of them, a highly acclaimed professor at a very prestigious university, e-mailed me back to say that he would be very interested to discuss this me over the phone. However, shortly afterwards, he mailed me again to say that he had changed his mind! I can only assume that, bearing in mind his high profile, it would have been difficult for him to admit that he had neglected to even mention the importance of nasal breathing in his books.

Another reply I received was from a university professor in the Southern Hemisphere. In his reply he stated that the breathing could either be nasal or oral and neither was preferred. However, the third reply I received was from Professor Saki Santorelli, who at the time was professor of medicine and executive director of the University of Massachusetts, Medical School Center for Mindfulness in Medicine, Health Care and Society. In his reply to me, Professor Santorelli stated:

“I very much appreciate your concerns. Indeed, for the entire 37 years of our existence, first as a Clinic and then as a Center with an MBSR (mindfulness based stress reduction) Clinic, we have used the Anapanasati Sutta as one of the foundational theoretical underpinnings of MBSR.  Of course, this includes emphasizing with our patients/participants breathing through the nose, unless physical conditions preclude such a possibility.”

The Anapanasati Sutta is a discourse from the Buddha. “Anapana” means “in-breath and out-breath” “Sati” means “mindfulness” or present moment awareness that simply notices what is happening without in any way interfering, without adding or subtracting anything to or from the experience. It’s bare awareness. So, anapanasati means “mindfulness while breathing in and out”. “Sutta” means a discourse of the Buddha. Apparently, anapanasati was the Buddha’s favoured meditation technique.

It’s interesting to note that this clinic referred to above was founded by Professor Jon Kabat-Zinn who created the world famous MBSR (mindfulness based stress reduction) program. Kabat-Zinn was a student of Zen Buddhist teachers, including Thich Nhat Hanh. His practice of yoga and studies with Buddhist teachers led him to integrate their teachings with scientific findings.

If you would like some information on how modern mindfulness of breathing usually differs from the ancient wisdom of Anapanasati, I have described this in an article I had published in The Breathing Issue and on the Buteyko Clinic International website.

You may access this article via the link below.

https://buteykoclinic.com/the-ancient-wisdom-of-anapanasati-mindfulness-of-breathing-versus-modern-mindfulness-of-breathing/

Slow Paced Breathing

It has been proposed that the treatment of insomnia using CBT-I, can be aided by using slow, deep breathing as an adjunct therapy, and that this may be highly effective in initiating sleep as well as facilitating falling back asleep.

Slow breathing has been defined as breathing at any rate from 4 to 10 breaths per minute. The typical respiratory rate in humans is within the range of 10–20 breaths per min. The term ‘deep’ breathing is frequently misunderstood as meaning ‘big’ breathing i.e. taking big breaths. However, deep breathing is in fact diaphragmatic breathing (also called belly or abdominal breathing).

Pre-sleep arousal refers to the mental and physiological activation that individuals experience when trying to fall asleep. Pre-sleep arousal may lead to disrupted autonomic nervous system (ANS) activity during sleep. Slow breathing (i.e., breathing at a frequency close to 0.1 Hz (6 breaths per minute) may be a simple way to reduce pre-sleep arousal since it can enhance vagal activity and increase feelings of relaxation. Indeed, recent research has demonstrated that slow breathing performed before or at bedtime can improve sleep as measured by polysomnography (PSG).

Noradrenaline (norepinephrine) and adrenaline (epinephrine) are the main hormones used by the sympathetic nervous system that when released into the blood stream, act widely across the body and promote active body movement, alertness, and arousal. The increased circulating noradrenaline in insomniacs may inhibit sleep. In contrast, the effects of the parasympathetic nervous system are mediated by acetylcholine which promotes rest and relaxation.

A current theory on the cause of insomnia proposes that hyper-arousal characterized in part by chronic hyper activation of the sympathetic nervous system and/or parasympathetic hypo activation disrupts normal sleep onset latency, sleep quality, and sleep duration.

Research has found that many cases of insomnia are a result of hyper-arousal being present during the day and also at night time. This results in physiologic activation and is characteristic of what is referred to as the hyper-arousal model of insomnia. Essentially, it’s thought that sympathetic hyper-activity and/or parasympathetic hypo-activity may significantly influence the development and maintenance of a significant fraction of modern cases of insomnia.

Abnormalities in autonomic nervous system modulation may in part explain the elevated risk of cardiovascular disease in insomniacs. Studies on heart rate variability and insomnia reveal increased sympathetic activity while awake before sleep and during stage-2 non-REM sleep which support the theory that autonomic hyper-arousal is a major cause of insomnia. This state of increased nocturnal autonomic arousal in insomnia patients who are simultaneously exhausted is known as “tired but wired”.

For many people in today’s frenetic world, their sympathetic system is regularly overactive and this is a major promoter of sleep deprivation. A vicious cycle may be created in which stress leads to insomnia and insomnia leads to more stress.

Consistent practice of slow, steady deep breathing can reduce autonomic hyper-arousal so that an individual will be more relaxed when it is time to sleep. In contrast, irregular and fast breathing have been shown to result in sympathetic excitation.

Slow, deep breathing has also been shown to result in melatonin production. This promotes relaxation, but in addition, melatonin is an essential sleep-inducing hormone which promotes parasympathetic tone and inhibits sympathetic tone. Melatonin levels are lower in insomniacs and much lower in long-term insomniacs, suggesting that the longer a sleep disorder exists, the more severe it gets.

Resonant Frequency Breathing

  • Introduction

Excessive activity of the sympathetic nervous system is often described as the “fight or flight” response or the “stress response”. This is essentially an alarm reaction, when the body prepares for immediate self-protective actions by increasing breathing and heart rate, and diverting blood flow to the major muscle groups.

Parasympathetic nervous system activation is the body’s physiological and emotion regulation response, which in many ways is opposite to the “fight or flight” response. During a stressful event or when there is a possible threat, people normally experience an increase in the “fight or flight” response and a temporary reduction in parasympathetic activity. When the threat has passed, parasympathetic activity increases to help return heart rate, breathing, and other physiological functions to normal levels.

Not only is breathing rate changed by sympathetic and parasympathetic activity, but it is also true that breathing rate causes changes in sympathetic and parasympathetic activity. Many people habitually breathe rapidly, shallowly and in the chest, which is often accompanied by episodic breath holding, sighs, and gasping. This breathing pattern is often subtle and chronic, resulting in increased heart rate, blood pressure, gastro-intestinal distress, asthmatic symptoms, neck and shoulder tension, anxiety, emotional and physiological arousal.

  • Hyper-arousal model of insomnia

A current theory on the cause of insomnia proposes that hyper-arousal characterized in part by chronic hyper activation of the sympathetic nervous system and/or parasympathetic hypo activation disrupts normal sleep onset latency, sleep quality, and sleep duration.

Research has found that many cases of insomnia are a result of hyper-arousal being present during the day and also at night time. This results in physiologic activation and is characteristic of what is referred to as the hyper-arousal model of insomnia. Essentially, it’s thought that sympathetic hyper-activity and/or parasympathetic hypo-activity may significantly influence the development and maintenance of a significant fraction of modern cases of insomnia. The state of increased nocturnal autonomic arousal in insomnia patients who are simultaneously exhausted is known as “tired but wired”. A vicious cycle may be created in which stress leads to insomnia and insomnia leads to more stress.

  • Reducing pre-sleep arousal

It has been proposed that the treatment of insomnia can made more effective by using slow, deep breathing, and that this may be highly effective in initiating sleep as well as facilitating falling back asleep. The respiratory rate of most adults at rest is within the range of 12–20 breaths per minute. Slow breathing has been defined as breathing at any rate from 4 to 10 breaths per minute. The term ‘deep’ breathing is frequently misunderstood as meaning ‘big’ breathing i.e. taking big breaths. However, deep breathing is in fact diaphragmatic breathing (also called belly or abdominal breathing).

Many people with insomnia experience what’s referred to as pre-sleep arousal. This is the mental and physiological activation that individuals can experience when trying to fall asleep. Pre-sleep arousal may lead to disrupted autonomic nervous system (ANS) activity during sleep. Slow paced diaphragmatic breathing can be a simple way to reduce pre-sleep arousal since it can enhance vagal activity and increase feelings of relaxation. Indeed, recent research has demonstrated that slow breathing performed before or at bedtime can improve sleep as measured by polysomnography (PSG).

The consistent practice of slow, steady deep breathing can reduce autonomic hyper-arousal so that an individual will be more relaxed when it is time to sleep. Slow, deep breathing has also been shown to result in melatonin production. This promotes relaxation, but in addition, melatonin is an essential sleep-inducing hormone which promotes parasympathetic tone and inhibits sympathetic tone. Melatonin levels are lower in insomniacs and much lower in long-term insomniacs, suggesting that the longer a sleep disorder exists, the more severe it gets.

  • The vagus nerve

The brain and body are most relaxed and best positioned for falling into restful sleep when the vagus nerve is activated. The vagus nerve is the longest of the 12 cranial nerves, running from the brain through the heart to the gut. It is known for its role in the parasympathetic (also called ‘rest and digest’) nervous system. It regulates various bodily systems such as breathing, heart rate, and digestion. Diaphragmatic breathing at a slow pace can enhance how much the heart rate accelerates and decelerates with each breath, improving the tone of the vagus nerve.

  • Resonant/resonance frequency breathing

Optimal breathing rate, known as the resonant or resonance frequency, varies among individuals, and breathing at the resonant frequency has a much greater psychological and physical health benefit than breathing at a rate even slightly slower or faster. Optimal breathing rate ranges from 4.5 to 7.0 breath cycles per minute.

The ideal way to find the precise optimal breathing rate for an individual is to use biofeedback equipment to identify the precise breathing rate that maximizes coherence and the inhale-exhale difference in heart rate. When a person breathes at their resonance frequency their respiratory, cardio-vascular and autonomic nervous work can together in a synchronized manner and function more efficiently. Resonance frequencies help oscillating systems to interact with each other so that they can more respond effectively and adapt quickly and appropriately to changes in internal and external conditions (e.g. increase physical activity, stress, threat, temperature changes, metabolic activity etc).

Breathing is an oscillating system in our body that is under our voluntary control. Breathing has the ability to entrain, organise and regulate other oscillating systems, helping them to also oscillate at their optimal (resonance) frequency. We can voluntarily control our breathing to tune other oscillating systems e.g. our circulatory system, for better functioning. Heart rate and blood pressure both oscillate. They interact with and respond to each other’s oscillations as well as with the oscillations of breathing and the oscillating activity of the autonomic nervous system. In a healthy person, inhalation makes our heart rate go up and exhalation makes our heart rate go down.

While these normal responses tend to decline in people as they age or develop various diseases it seems that they can be improved with resonance frequency breathing. Breathing at resonant frequency is thought to maximize heart rate variability (HRV). HRV is a measure of the variation in time between each heartbeat. This variation is controlled by the autonomic nervous system. Measuring HRV is a non-invasive way to identify autonomic nervous system imbalances. If an individual’s system is in more of a fight-or-flight (stress response) mode, the variation between subsequent heartbeats is low. If they are in a more relaxed state, the variation between beats is high. Research has shown a relationship between low HRV and worsening depression or anxiety. A low HRV is also associated with an increased risk of death and cardiovascular disease. Individuals who have a high HRV may have greater cardiovascular fitness and are thought to be more resilient to stress. Resonant frequency breathing can increase HRV and its potentially positive effects.

Hyperventilation, mouth breathing and nasal breathing

Hyperventilation (over-breathing) is characterised by taking bigger and faster breathes than normal. This results in minute volumes that are much higher than normal. Minute volume is the volume of air inhaled or exhaled from a person’s lungs in one minute. In one study, males with sleep apnoea were found to breathe about double the accepted physiological norm with average minute volumes of about 15 litres/minute (normal is about 6 to 7) during the day. This is part of a growing body of research confirming chronic hyperventilation and dysfunctional breathing patterns are significant risk factors in sleep apnoea.

Over-breathing stimulates the sympathetic branch of the autonomic nervous system and places the body on alert mode. Insomnia sufferers typically exist in a permanent state of sympathetic stimulation and while this may go unnoticed during daylight hours, the resulting busy chattering mind limits the chances of a night of good quality sleep.

Over-breathing is much less likely to occur with nose breathing and the mouth closed. Also, it is well documented that mouth breathing adults are more likely to experience sleep disordered breathing than those who nasal breathe. They are also more likely to experience decreased productivity and poor quality of life.

Leading advocates of the Buteyko method of breathing retraining believe that teaching clients to breathe gently, using the nose (for inhalation and exhalation), with lower breathing volumes, serves to counter the consequences of the Bernoulli Principle whereby the pharynx collapses due to excessive airflow generating an increase of negative pressure. In other words, collapse occurs because the negative pressure generated in the upper airway, as the breath is drawn into the lungs, is greater than the dilating force of the upper airway dilator muscles.

A study demonstrated that mouth opening, even in the absence of oral airflow, increases the propensity of the upper airway to collapse. Mouth breathing has also been shown to be associated with reduced response of the genioglossus muscle. The genioglossus serves as the major airway dilator muscle.

Because Buteyko breathing reduces the breathing volume and brings it closer to normal, it thereby reduces turbulence and negative pressure in the upper airway. Light, quiet and calm nasal breathing can reduce both snoring and obstructive sleep apnoea as well as eliciting the body’s relaxation response, contributing to deeper, more restorative sleep.

Several research studies have showed how breathing through the nose offers a distinct advantage during sleep, resulting in fewer incidences of obstructive sleep apnoea than when a patient breathes through the mouth at night.  In fact, in one study, the wearing of a chin strap to prevent mouth breathing, demonstrated the same or better results in improving severe obstructive sleep apnoea than the use of a CPAP machine (the current Gold standard treatment for obstructive sleep apnoea). Nasal breathing is essential for good quality sleep.

The approximately 7 minute long video, which you can access via the link below, features world renowned breathing retraining expert Patrick McKeown. In it, Patrick explains how nasal breathing can improve the quality of your sleep.

https://www.youtube.com/watch?v=MLjVIAtgKvo&t=47s

Research findings re mouth and nose breathing

Briefly, the findings and conclusions from a range of other research studies, carried out by various researchers over the last 18 years, have included the following:

  • The habit of mouth breathing during sleep is to some extent age-related. By the time you reach 40, you are around 6 times more likely to spend at least 50% of your sleep switching between nasal and oral breathing.
  • Open-mouth breathing during sleep is a risk factor for obstructive sleep apnoea (OSA) and is associated with increased disease severity and upper airway collapsibility.
  • Upper airway resistance during sleep and the propensity to obstructive sleep apnoea are significantly lower with breathing through the nose compared to breathing through the mouth.
  • Open-mouth breathing during sleep may increase the severity of obstructive sleep apnoea (OSA) and complicate nasal continuous positive airway pressure (CPAP) therapy in patients with OSA.
  • Obstructive apnoeas and hypopnoeas are profoundly more frequent when breathing orally (apnoea-hypopnoea index 43+/-6) compared to nasally (1.5+/-0.5).
  • Mouth breathing generally develops because the ability to breathe nasally is impaired in some way.
  • Airflow velocity is significantly higher during mouth breathing than during nasal breathing with open or closed mouth.
  • Mouth breathing is the primary condition leading to pharyngeal airway collapse based on the concept of the Starling Resistor model.
  • Airflow throughout the entirety of the breathing route is smoother during nasal breathing with closed mouth than that with open mouth.
  • During sleep (supine, stage 2) upper airway resistance was much higher while breathing through the mouth compared to breathing through the nose.
  • Nasal congestion typically results in a switch to oronasal (mouth/nose) breathing that compromises the airway.

Are you an open mouth snorer?

Mouth breathing is one of the most common causes of snoring. If you aren’t sure if you are an open mouth snorer or a nose snorer, you can do this simple test – In a comfortable, reclined sleeping position, try to create a snoring noise with your mouth open. Then close your mouth and try to create a snoring noise. If you are only able to snore with an open mouth, then you are an open mouth snorer. If you are able to snore with the mouth closed, then you are a nose snorer.

Snoring is a coarse sound made by vibrations of the soft palate and other tissue in the upper airway. It occurs when part of the throat air passage collapses and vibrates. When someone is asleep, the muscle tone in the tongue, soft palate and neighbouring structures decreases. This allows collapse and vibration of these structures when breathing, thereby causing snoring.

Anything that obstructs the airway can contribute to snoring, e.g. large adenoids or a large tongue. The underlying cause of snoring is the exchange of a relatively large volume of air through a narrowed space, which causes the tissue in the upper airway to vibrate. The sound most often occurs when you breathe air in, and can come through the nose, mouth or a combination of the two.

Mouth breathing is a very common cause of snoring. Also, if you often wake up with a dry mouth and sore throat, it’s likely that mouth breathing was the underlying cause.

Sleeping with your mouth open can result in many negative effects, for example:

  • Your airway is narrowed as your tongue falls further back into your airway and the open space between your tongue and soft palate is reduced.
  • The inhaled air becomes turbulent,vibrating the soft tissues at the back of your mouth, resulting in the sound of snoring.
  • Your upper airway becomes drybecause unlike nasal breathing, mouth breathing doesn’t humidify the incoming air.
  • You are more susceptible to colds, flu, allergic reactions, hay fever, irritable coughing

In addition to impacting negatively on sleep quality, mouth breathing can bring many other problems. To learn more about the possible adverse consequences of chronic mouth breathing and the numerous benefits of nose breathing, please see my article titled ‘The health benefits of nose breathing’ which you can access via the following link:

the-health-benefits-of-nose-breathing.pdf (rackcdn.com)

Obstructive Sleep Apnoea (OSA)

One of the important benefits of nose breathing is that it reduces the likelihood of snoring and the risk of developing the potentially serious disorder called obstructive sleep apnoea (OSA). Nose breathing can also reduce the severity of OSA by reducing the frequency of apnoeas and hypopnoeas.

Snoring and sleep apnoea are the most common sleep related breathing disorders. It’s estimated that half of all adults snore at least occasionally and that 25 percent are habitual snorers. It’s also estimated that 30-50% of snorers actually suffer from sleep apnoea, and that up to 5% of adults in Western countries are likely to have undiagnosed OSA.

OSA is by far the most common form of sleep apnoea. It’s estimated to account for over 80% of cases of sleep related breathing disorders. OSA is defined as the cessation of airflow (caused by an obstruction) during sleep, preventing air from entering the lungs. Eventually, the consequent loss of breath causes the nervous system to send an alarm signal to the brain resulting in the person arousing momentarily. This comes about as a result of the increase in carbon dioxide which causes the sympathetic nervous system to release stress hormones. This reactivates the muscles that hold the throat open, the person breathes again and falls back to sleep. Typically there is a gasp or snort and their body shudders as they arouse. Usually the sufferer is totally unaware that they were momentarily jolted awake. The apnoeas prevent the sufferer from entering or spending adequate time in the deep restorative sleep stage. They also deprive the sufferer’s tissues and organs of oxygen.

Left untreated, OSA can have life-shortening consequences. If you would like to learn more about OSA and its possible life shortening consequences, please see my article titled ‘Obstructive Sleep Apnoea in Adults’ which you can access via the following link:

Article1Sept14.pdf (lenus.ie)

CBT-I for patients with comorbid insomnia & sleep apnoea (COMISA)

Insomnia and obstructive sleep apnoea (OSA) frequently co-occur and result in a highly prevalent and debilitating condition called Comorbid Insomnia and Sleep Apnoea (COMISA). It’s thought that the two components of COMISA may be causally related through sleep fragmentation and/or hyperarousal mechanisms. Based research conducted in recent years, 30–50% of OSA patients report insomnia symptoms, while 30–40% of insomnia patients fulfil the diagnostic criteria for OSA.

Insomnia and OSA share a number of negative consequences. These include increased cardiovascular risk and decreased health-related quality of life. Together, the two disorders combined show an increase in cumulative morbidity and an overall greater illness severity than either disorder alone. It’s generally accepted that OSA can either cause insomnia or exacerbate it. Also, it has been suggested that adequate OSA therapy can result in an improvement of insomnia symptoms.

COMISA patients experience greater impairments to daytime functioning and quality of life, compared to those with either insomnia, or OSA alone. They also show lower acceptance and use of Continuous Positive Airway Pressure (CPAP) therapy, compared to patients with OSA alone. CPAP therapy is the most effective treatment for moderate and severe OSA. It stabilises breathing throughout the night, improves daytime sleepiness and quality of life, and reduces risk of motor-vehicle accidents. However, CPAP therapy requires patients to wear pressurised nasal or oro-nasal masks throughout the night, and is limited by poor patient acceptance and poor long-term adherence. Research indicates that the presence of insomnia reduces CPAP acceptance and use of CPAP. Understandably, patients who spend long periods awake wearing pressurised CPAP masks throughout the night are more likely to experience CPAP-related side effects. As a consequence, they will be more likely to remove the CPAP equipment during the night, or reject CPAP therapy altogether.

Importantly, and in conclusion, research studies have shown that COMISA patients who have CBT-I, before the start of CPAP treatment, have improved insomnia symptoms and improved CPAP use, as compared to those who commence CPAP treatment without CBT-I. Research has also shown that in COMISA patients, CBT-I consolidates sleep periods and promotes a 15% decrease in OSA severity.

OSAHS phenotypes & new treatment possibilities

Introduction

Obstructive sleep apnoea (OSA) is also referred to as obstructive sleep apnea-hypopnoea syndrome (OSAHS). However, OSAHS is also sometimes described as OSA that’s associated with excessive daytime sleepiness.

The current main treatments for OSAHS are continuous positive airway pressure (CPAP) and mandibular advancement devices (MAD). CPAP is currently viewed as the ‘gold standard’ treatment for OSASHS. However, many patients struggle with CPAP and adherence rates are unacceptably low, in that it has been estimated that 46 to 83 percent of patients have been reported not to adhere to treatment. Factors that may be involved in non-adherence include: nasal obstruction, claustrophobia, poor social support, mouth leaks that can lead to arousals, and drying of the airways.

MADs have better patient adherence than CPAP but they are not recommended for patients with severe OSAHS. Also, the reduction of AHI (Apnoea-Hypopnoea Index) is less, and various side effects can occur. These can include: craniofacial changes, excessive salivation, dry mouth, dental pain, gingival irritation, myofascial pain and temporomandibular joint pain. Upper airway surgery can be beneficial in many patients but it has variable and unpredictable efficacy. Due to these problems with current standard treatments, new and better accepted approaches to treat OSAHS are needed.

OSAHS phenotypes

The current standard treatments for OSAHS mentioned above, are anatomically focused. The reason for this is that a narrow or collapsible upper airway (‘impaired anatomy’) has long been viewed as the primary cause. However, it’s now known that the contribution of anatomy to the causation of OSAHS varies considerably. Indeed, impairment in pharyngeal anatomy can be modest in about a fifth of patients whose pharyngeal collapsibility while asleep is the same as for people without OSAHS.

Over the past seven to eight years, there has been increasing recognition that OSAHS is not simply an anatomical issue. In other words, the cause of OSAHS differs from one individual to another, and the combination of causative factors can vary from patient to patient. In recent years, four key contributors to OSAHS pathogenesis (development) or “phenotypes” have been identified and characterized. These are a narrow, crowded, or collapsible upper airway (impaired anatomy), and three ‘non-anatomical’ contributors i.e. ineffective pharyngeal dilator muscle function during sleep, a low threshold for arousal to airway narrowing during sleep (low respiratory arousal threshold), and unstable control of breathing (high loop gain).

This means that anatomically based treatments for OSAHS may not fully resolve the condition. In addition, current standard treatment has adherence and side effects issues associated with them. This has resulted in a growing interest in other possible treatment approaches that will provide the basis for personalised treatment protocols. As adherence rates for CPAP patients are unacceptably low, an alternative approach for non-adherent patients would be to target one or more of the non-anatomical/physiological factors that contribute to OSA pathogenesis.

Addressing a breathing disorder with breathing re-training

Since OSAHS is classified as a sleep related breathing disorder, it seems reasonable and logical to assume that breathing re-training may be helpful across all 4 phenotypes of this disorder.

Through breathing re-training, it’s possible to manipulate breathing patterns during wakefulness using exercises that target the biochemistry, biomechanics and frequency of breathing. In this way, breathing can be “trained” so that nasal breathing is restored or increased, diaphragm function is improved, respiratory rate is slowed, and there is increased tolerance to changes in arterial carbon dioxide (CO2) pressure. By addressing poor breathing patterns during wakefulness, it’s likely that this will provide a mechanism whereby sleep-disordered breathing can also benefit. The benefit is likely to be greatest in those patients will minimal anatomical risk factors for OSAHS.

Research to date has demonstrated that a variety of breathing re-training approaches can improve sleep apnoea metrics and/or clinical symptoms. These approaches include, for example, the Buteyko Breathing Method, inspiratory resistance training, and diaphragmatic breathing. Additional research is urgently required to investigate the therapeutic benefits of targeting the biochemistry, biomechanics and frequency of breathing by restoring nasal breathing and other functional breathing patterns.

The foundation of the Buteyko breathing re-training method is to breathe only through the nose, both during waking hours and while asleep. Nasal breathing with the tongue resting in the roof of the mouth helps to ensure that the airway is larger. This reduces the risk of sleep problems including OSAHS. Earlier in this section, some pertinent research conclusions concerning breathing route (nasal versus mouth) and OSAHS were cited. These were the following:

  • Open-mouth breathing during sleep is a risk factor for obstructive sleep apnoea (OSA) and is associated with increased disease severity and upper airway collapsibility.
  • Open-mouth breathing during sleep may increase the severity of obstructive sleep apnoea (OSA) and complicate nasal continuous positive airway pressure (CPAP) therapy in patients with OSA.
  • Obstructive apnoeas and hypopnoeas are profoundly more frequent when breathing orally (apnoea-hypopnoea index 43+/-6) compared to nasally (1.5+/-0.5).
  • Mouth breathing is the primary condition leading to pharyngeal airway collapse based on the concept of the Starling Resistor model.
  • During sleep (supine, stage 2) upper airway resistance was much higher while breathing through the mouth compared to breathing through the nose.
  • Upper airway resistance during sleep and the propensity to obstructive sleep apnoea are significantly lower with breathing through the nose compared to breathing through the mouth.
  • Nasal congestion typically results in a switch to oronasal (mouth/nose) breathing that compromises the airway.

In addition to establishing full-time nasal breathing i.e. during waking hours and during sleep, other fundamental aspects of the Buteyko breathing re-training method are:

  • Slowing the breathing rate
  • Ensuring the correct resting posture of the tongue
  • Restoring diaphragmatic function and the lateral expansion of the lower ribs
  • Using breath-hold time (the Control Pause) to establish chemosensitivity to carbon dioxide (CO2)
  • Decreasing the minute volume (the volume of gas inhaled or exhaled per minute) towards normal to regulate levels of carbon dioxide (CO2)

If you would like to learn more about breathing re-training (re-education) and phenotypes of OSAHS, I would recommend a review article by McKeown et al; published in February 2021 in Journal of Clinical Medicine. You may access this article via the link below.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865730/

Playing wind instruments or singing

The September 2020 issue of Journal of Clinical Sleep Medicine published the results of a systematic review and meta-analysis of the current scientific literature on the role of playing musical wind instruments or singing in alleviating the risk of OSAHS, snoring, and related symptoms of sleep disturbance and daytime sleepiness.

Interesting conclusions were drawn from studies included in the study. For example, players of double reed wind instruments or a didgeridoo and singers were particularly noted to have the following:

  • A positive impact on the risk of OSAHS i.e. decreased risk
  • A reduced AHI (Apnoea-Hypopnoea Index)
  • A reduction in snoring, sleep disturbances, and daytime sleepiness

The above outcomes suggest a potential role of a selective pattern of muscle activation and oropharyngeal air pressure achieved in playing certain orchestral wind instruments and singing, in alleviating snoring and OSAHS. These findings lend support to the fairly recent hypothesis that certain exercises (from myofunctional therapy) that improve oral and oropharyngeal muscle tone will reduce collapsibility of the airway during sleep and decrease tongue fat deposition, potentially playing a role as a treatment alternative for OSAHS.

Ref: https://jcsm.aasm.org/doi/10.5664/jcsm.8706

Important notes

  • If you are a regular snorer, you should not assume that it’s ‘just snoring’. You need to be aware that you might have the potentially much more serious disorder Sleep Apnoea. The link below enables you to access a short article I wrote for community pharmacists titled ‘It might not be ‘just’snoring’. The article includes a series of questions. A ‘yes’ answer to one or more of these questions may indicate that you might have sleep apnoea. The article appears on page 28 of the publication. Please note that the series of questions do not constitute a definitive test/evaluation for sleep apnoea.

IRISH_PHARMACIST_SEP_14.pdf (greencrosspublishing.ie)

  • If as a result of completing the initial assessment during session (1) of a CBT-I program, Alan suspects that a client might have sleep apnoea, he will advise the client to consult their general practitioner (GP). If as a result of the GP’s clinical evaluation, they also suspect sleep apnoea, they will most probably refer the individual for diagnostic polysomnography. Polysomnography records brain waves, breathing effort and rate, air flow in and out of the lungs, oxygen levels in the blood, heart rate, eye movement and electrical activity of muscles. It can determine the severity of sleep apnoea (if present) and identify other possible sleep disorders.