SNORING – SLEEP APNOEA - ASTHMA CROOKED TEETH ... WHAT’S THE LINK?
Glenn White BSc MSc MBIBH BIBH
Practitioner/trainer
www.buteykobreathing.co.nz
BREATHING AWARENESS
1.
Count the number of breaths you take in one minute
2.
Place one hand on upper chest, one hand on belly
- take 2 breaths in and out through the nose and note
relative hand movements
- repeat breathing through open mouth
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FUNCTIONAL BREATHING
Breathing Parameter
Normal characteristics
Route
Nose: rest, physical exercise, sleep
Location (dominant)
Diaphragm
Respiration rate
8-12 breaths per minute
Minute volume
4-6 litres per minute
Tidal volume
500 ml per breath
Feel of breathing
Easy, comfortable, satisfying
Rhythm
Regular, smooth
Sound
Inaudible; at rest, sleep
Heart rate
60-80 beats per minute
After Graham, T 2012, Relief from snoring and sleep apnoea
DYSFUNCTIONAL BREATHING
Breathing Parameter
Characteristics
Route
mouth breathing or heavy nose breathing
Location (dominant)
Thoracic dominant
Respiration rate
> 14 breaths per minute
Minute volume
> 9 litres per minute *
Appearance of breathing
obvious upper chest or abdominal movement
Feel of breathing
Heavy, windy full breaths
Rhythm
Irregular: sighs, yawns, coughs, sniffs
Sound
Audible; at rest, sleep (snoring)
After Graham, T 2012, Relief from snoring and sleep apnoea
DAYTIME SYMPTOMS OF DYSFUNCTIONAL BREATHING
Blocked or runny nose
Throat clearing
Open-mouth breathing
Short of breath on exertion
Heavy laboured breathing
Upper chest breathing pattern
Wheezing, asthma, chest tightness
Anxiety/ panic attacks
Sighing or frequent deep breaths
Dry mouth
Frequent yawning
Difficulty swallowing
Irritable cough
Gastric reflux
NIGHT-TIME SYMPTOMS OF DYSFUNCTIONAL BREATHING
Breathing Disordered Sleep
• difficulty getting off to sleep
• restless sleep, frequent waking
• waking up-tired
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SYMPTOMS OF BREATHING DISORDERED SLEEP
Snoring
restless sleep
sleep apnoea
restless leg syndrome
insomnia
increased nasal congestion
vivid dreams-nightmares
teeth grinding
night-time cramps
sleep-walking, sleep-talking
frequent urination, bed wetting
morning headache
night thirst, dry mouth on waking
blocked nose on waking
groggy on waking
morning thirst
asthma, night-time coughing
high morning pulse
night-time anxiety/panic attacks
messy bed on waking
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MORNING BREATH
THE LUNGS AND CARBON DIOXIDE (CO2)
One of the lung’s primary functions
is to maintain optimum levels of O2
and CO2 in airways and blood
Mouth breathing and over-breathing result in CO2
loss resulting in CO2 deficit (hypocapnia)
The Importance of CO2
•
An optimal level of CO2 is essential in airways and blood
for oxygen delivery to brain and body tissues
•
CO2 is a broncho/ vaso dilator
•
Optimal PaCO2 is essential for the release of oxygen
1
from blood to body tissues (The Bohr Effect)
1
DAVIS FREED Am.J.Respir.Crit. Care Med.2001, 785-789
OVER-BREATHING AND CO2 LOSS
REDUCES BRAIN OXYGEN
MRI SCAN
red - yellow = highest oxygen
dark blue = least oxygen
The right hand image shows a 40% reduction in brain oxygen after one
minute of big volume breathing. This explains the sensation of dizziness
that often accompanies a panic attack. (source Litchfield 1999)
Dysfunctional breathing = hyperventilation
Hyperventilation = breathing more than the medical norm
Normal resting minute volume for a 70-kg human
4-6 litres/min for older physiological textbooks
6-9 litres/min for some modern textbooks
> 9 litres/min is defined as hyperventilation
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HUMAN BREATHING VOLUMES HAVE DOUBLED IN FIFTY YEARS
Minute Ventilation, litres per mniute
14
12
12
11
12
12
10
8
6.9
6
6
4.9
5.3
7.8
4.6
4
2
0
Norm
1929
1939
1939
1950
1980
1990-96
1997
1998-99
Information sourced from 24 medical studies – Rakhimov 2005
2000s
Hyperventilation (over-breathing)
- a mechanism that is often overlooked in asthma.
Average MV measured for asthmatics in Brisbane Buteyko
trial - 15 litres per minute (normal 10 litres) 1
Hyperventilation whether spontaneous or exercise induced, is
known to cause asthma 2, 3, 4
Loss of CO2 through hyperventilation can trigger
bronchoconstriction in asthmatics 4, 5
1
Bowler S, Green A, Mitchell C, Medical Journal of Australia 1998; 169: 575-578
Demeter & Cordasco The American Journal of Medicine, (1986), vol 81 pp 989.
3 Clarke PS, Gibson, JR Aust Fam Physician. 1980
4 Sterling, GM., Clin Sci, (1968), vol 34, pp 277-285
5 van den Elshout, FJJ et al., Thorax, (1991), vol 46, pp 28-32
2
HYPERVENTLATION - HYPOCAPNIA AND ASTHMA
Hyperventilation and hypocapnia (CO2 deficit)
are common in asthma 1, 2, 3
Hypocapnia is the rule in asthma until respiratory
failure sets in 3
1 Tobin, MJ et al. Chest, 1983; 84:287-294.
2 Hormbrey, J. et al., European Respiratory Journal, 1988;1: 846-852.
3 Clarke, PS., Australian Family Physician. 1980; Vol 9, October
HYPERVENTLATION - HYPOCAPNIA - INFLAMATION
Hypocapnia can trigger mast cell de-granulation and
histamine release
• airways – asthma, hay fever
• skin – eczema
• gut – food allergies, irritable bowel (IBS)
Perera, J. The hazards of heavy breathing. New Scientist, Dec 1988
Kontos et al. American Jnl of physiology 1972
Coakley et al. Jnl of Leukocyte Biology 2002:71
Strider et al., Allergy 2010
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HYPERVENTLATION – SLEEP APNOEA - ASTHMA
Average tidal volumes of 950ml and
average minute volumes of 15 litres per
minute during the day were recorded in
males diagnosed with sleep apnoea 1
CPAP reduces hyperventilation
while applied 2
Asthma improves with breathing
control, through application of
Continuous Positive Airways Pressure 3
1
Radwan et al., Eur Resp J 1995
2 Naughton M, Benard D, Rutherford R, Am J Respir Crit Care Med 1994;
3 Chan C, Woolcock A, Sullivan C. Am Rev Respir Dis 1989
CONSEQUENCES OF OVER-BREATHING:
•
•
•
carbon dioxide deficit – hypocapnia
•
•
•
disruption in breathing regulation
•
•
•
•
reduced oxygenation
•
histamine production
dehydrated and inflamed airways
increased mucus production
smooth muscle constriction
- bronchial, cardiovascular, gastrointestinal, urinary
- broncho-spasm, vaso-constriction, Verigo-Bohr Effect
pH disturbance
bigger breathing volume = more inhaled irritants
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OVER- BREATHING CHECKLIST
•
•
•
•
•
•
•
•
•
•
•
•
habitual mouth breathing
audible breathing
nasal congestion/ mucus
upper chest breathing pattern
poor posture, shoulders high, forward, slouching
frequent sighing or yawning
large inhalations through mouth when speaking
rapid breathing rate > 15 breaths/minute
paradoxical (reverse) breathing
irregular breathing pattern, breath-holding
cold hands and feet
dry skin: face, lips, hands and feet
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STRESS MAKES US BREATHE MORE
If the stress is prolonged over-breathing becomes habitual
•
stress in workplace, school, home, bereavement, financial
• illness, infection
• lack of exercise, athletes over-training
• over-eating, skipping meals, too much refined carbs, low protein
• some medications; e.g. bronchodilator medications
• caffeine, nicotine, alcohol, recreational drugs
• promotion of deep breathing techniques
• computer games, excessive use of personal technologies
IN SUMMARY LIFE
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MOUTH BREATHING AND TONGUE POSITION
• Nasal breathing with tongue in the roof of the mouth helps
iiiensure wide dental arches and straight teeth
• The tongue is one of the strongest muscles in the body, capable
of exerting 500 grams of pressure.
• It only takes 1.7 grams of pressure to move a tooth.
• Mouth breathers carry the tongue in the floor of the mouth
potentially leading to narrow dental arches, crowded teeth,
receding chin, smaller jaw and risk of sleep apnoea
Normal wide arches
Narrow arches
No room for tongue here
Lateral airway views of a
Mouth breather
Nasal breather
Note low tongue posture
Note correct tongue posture
CT SCANS
nose breather
mouth breather
Mandibular advancement showing
opening of airway
MOUTH BREATHER
Uncorrected open-mouth
breathing is likely to result in:
• crooked teeth
• narrow dental arches
• receding chin
• protruding nose
• narrow airway
• and high risk of developing
obstructive sleep apnoea by
the age of thirty
Anterior open bite, narrow upper arch
Bolton
standard
Mouth breathing at an early age can effect dental arch
development. Narrow jaws can lead to crooked teeth and a
distorted facial profile. If the underlying mouth breathing habit
is not corrected features become more exaggerated with age.
DENTAL DISORDERS LINKED TO OPEN MOUTH BREATHING
• dental decay
• malocclusion
• narrowing of dental arch
• dental crowding, crooked teeth
• cross-bite
• anterior open bite
• gum disease, bad breath
• inflammation of adenoids and tonsils
• TMJ dysfunction
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SNORING AND SLEEP APNOEA EXPLAINED
- it’s your breathing
breathing stimulated
blood pH normalising
O2 release to cells
snoring
over-breathing
inflame/narrow airways
vibration noise
suction effect
CO2 increase
obstructive
sleep apnoea
CO2 deficit
(hypocapnia)
CO2 < apnoeic threshold
cellular hypoxia
central
sleep apnoea
SNORING - SLEEP APNOEA AND BRAIN HYPOXIA
MRI scan
red - yellow = highest oxygen
dark blue = least oxygen
This may might help explain the link between sleep apnoea
and a higher incidence of cancer 1 and Alzheimer’s 2
1 Dr. F. Javier Nieto
2 Osorio et al 2013
BUTEYKO BREATHING RETRAINING
Who are our clients:
• Asthma
• Chronic nasal congestion
• Allergic rhinitis
• Sleep apnoea, chronic snorers
• Panic attack
• Dental disorders resulting from open-mouth
breathing
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BUTEYKO BREATHING RETRAINING
To normalise each aspect of the breathing pattern:
• Rate
• Rhythm
• volume
• Mechanics - correct use of breathing muscles
• Use of the nose - inhale/exhale
- For all situations: awake, asleep, at rest, when eating,
speech and physical exercise
Tess Graham – Relief from Snoring and Sleep Apnoea p 80
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THE NOSE
YOUR PORTABLE AIR CONDITIONER
• warms
• filters
• humidifies
• disinfects (germicidal action of NO
in paranasal sinuses 1
• nasal breathing increases arterial
CO2 by 20% and O2 by 8% 2
1
Lundberg Anat Rec 2008
2
Swift et al Lancet 1988
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NOSE UN-BLOCKING EXERCISE
1.
2.
3.
Breathe in and out normally through nose
Hold on the out breathe for as long as is comfortable
Then gradually resume very gentle breathing
It may help to pinch the nose and
nod your head a few times
In stubborn cases or when the
blockage is due to a cold, the
exercise may need to be repeated
several times
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DIAPHRAGM BREATHING EXERCISE
• sit with upright posture on a stable firm chair
• move to the front edge of the chair, upper
legs parallel with the floor, knees directly
over the ankles
• practise breathing gently into the belly
Breathe slowly, rhythmically and gently
making each breath as small as you can
• Do this for 3-5 minutes a few times a day to
help tone the diaphragm and reduce upper
chest breathing
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Small
movements
REDUCING BREATHING VOLUME
An exercise to help habituate to reduced breathing volume
• Hold the index finger under your nose
to feel how much air goes in and out.
• When you are breathing normally you will
feel warm air across your finger on the
out-breath and cool air on the in-breath.
• Try slowing your breathing down until you
hardly feel any air across your finger.
• If you have a healthy breathing pattern you
should be able to maintain this sensation of
no air on your finger for five minutes or more.
can
FEATHER BREATHING
Soft invisible breathing as practised by the Samurai
TWO TO FIVE BREATHING EXERCISE
You can use this breathing exercise to de-stress, help overcome
an anxiety/panic attack, relieve breathlessness, chest tightness or
asthma and to help you sleep.
This exercise can be done sitting, standing or lying down. Try to
breathe gently through your nose and breathe from the belly.
BREATHE WELL – SLEEP WELL
Breathe well by day and you will breathe well by night
• Nose breathing by day and you are more likely to nose breathe
during sleep; try to sleep with mouth closed
• Do some nose clearing and breathing exercises prior to sleep
• Sleep with upper body slightly elevated
• Avoid sleeping on back, left is best
• Avoid stimulating foods, drinks and activities at least 90minutes before sleep
• Turn screens off at least 60 minutes before sleeping
• Sleep in a dark, well ventilated room, do not get over-heated
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Foods that adversely affect breathing and may trigger
asthma, nasal congestion, snoring, poor sleep or headache
• Foods containing refined white flour, sugar:
refined breakfast cereals, pasta, noodles, cakes, cookies
• Drinks with added sugar: soft drinks, fruit juice ...
• Milk and milk products, goats milk, soy milk, protein shakes
• Soft cheeses, cottage cheese, ice cream, yoghurt
• Chocolate
• Caffeine, alcohol
• Food additives; MSG, sulphites, sodium benzoate, nitrites,
aspartame
Note: over-eating leads to over-breathing
BREATHING AND SPEAKING
Breathing tips for talking:
• Try to talk less
• Talk more slowly
• Breathe in through your nose at the start of each
sentence
• Do not take a big breath in before speaking
• Breathe more gently and quietly when talking
• Speak in shorter sentences
BREATHING GUIDELINES FOR ASTHMA RELIEF
Guidelines for reducing minute volume and
normalisation of the breathing pattern
•
Instruct to nasal breathe if possible
•
Slow breathing rate and try to reduce breathing volume
•
Try to breathe diaphragmatically
•
Reduce or eliminate consumption of dairy products
•
Reduce or eliminate refined carbohydrates especially foods
and drinks with added sugar
•
Sleep on the left side with head elevated
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ASTHMA AND SPORT
•
Instruct to breathe through the nose, whenever possible
to help maintain the bronco dilating effects of CO2 in
airways
•
•
•
Adjust intensity to allow comfortable nasal breathing
Drop shoulders and breathe from diaphragm
Slow the rate and reduce breathing during breaks in play
and after physical exertion to boost cellular O2 and
reduce lactic acid
•
We instruct not to pre-dose with reliever medication but
to carry at all times and use if needed.
1
1
Any changes to prescription medication, where appropriate, are undertaken
by the clients’ prescribing doctor.
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SIX THINGS YOU CAN DO:
1. Instruct on the importance of nasal breathing for ADL
2. To maintain nasal breathing at rest, during physical exertion, sleep
3. Correct tongue posture; with tongue in roof of the mouth
4. To supress yawns and the urge to sigh, gasp, cough, snort, sniff
5. Instruct on nasal clearance using the nose un-blocking exercise
6. Instruct on diaphragmatic breathing
BUTEYKO BREATHING CLINIC PROGRAM
•
*
Four initial, consecutive 90-minute
breathing retraining sessions
•
Two follow up sessions within six weeks
•
Telephone support and additional sessions if
required for six weeks
•
Breathing exercises practised for six weeks
•
Life-long awareness of the concepts is recommended
•
course fee $605
•
Ages four and up
•
Referral not essential
* Buteyko clinic practitioners teach the Buteyko Institute Method of breathing retraining.
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THE TEAM- BIBH PRACTITIONERS
Glenn White
Practioner
trainer
Auckland
Tricia Enriquez-Gault
Auckland
Olga Horne
Auckland
Susan Allen
Wanaka
Viv Smith
Queenstown
OUR TRAINEES
Melody Sloggett
Auckland
Pia Schroeter
Auckland
Eddie Johnson
Auckland
Arisa Shioda DS
Japan
Ines Steward
Auckland
Dina Ceniza
Auckland
Our practitioners teach to Buteyko Institute of Breathing and Health (BIBH) standards.
The BIBH is ISO 9001:2008 Certified