Tess Graham's lecture on the Airway and Facial Development spree cast 10/27/14

1. Breathing Dysfunction, Sleep and
Airway Issues
The breathing retraining approach
Tess Graham
Physiotherapist, Breathing Educator
BSc. Grad Dip Physiotherapy; Dip Buteyko Breathing Method
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2. Physiological norm – awake
• Rhythmic, regular
• Silent
• Nasal
• Diaphragmatic
• RR: 8-12 breaths/minute
• TV: 500 mls/breath
• MV: 4-6 litres/minute
• CO2: 40-45mmHg
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3. Physiological norm – asleep (1)
• Nose-breathing
• Diaphragmatic
• Regular -NREM; some irregularity-REM
• RR: some increase in REM, NREM
• TV and MV reduce
• Decreased tone pharyngeal dilators
• O2 asleep < awake
• CO2 increases 3-7mmHg
3

4. Dysfunctional breathing - awake
• Irregular – sigh, yawn, cough
• Audible, noisy
• Mouth-breathing
• Upper-chest breathing
• > 14 breaths/minute
• TV - 950 mls/breath OSA
• MV - 8.8 L/min ‘simple’ snorers
- 15 L/min OSA
- 14L/min OHS
4

5. Dysfunctional breathing - asleep
• Irregular, chaotic
• Audible, noisy
• Mouth-breathing
• RR: 17-38 breaths/min
• TV: increases
• MV: to 20L CSA; 22L OSA
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6. Comparison
Normal
Sleep apnea
Respiration Rate
8-12
16-38 (Graham)
Tidal Volume
500mls
950mls (Radwan)
Minute Volume
4-6 L 13L (Awake – Esquivel CSA)
14L (Awake - Redolfi OHS)
15L (Awake - Radwan OSA)
20-22L (Asleep - Xie, Graham)
Insp. Flow Rate
280mls/sec (Douglas)
620 mls/sec (Radwan)
CO2
40-45mmHg
Hypocapnia, Hypercapnia, Normocarbia
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7. Comparison
V Lunn-Rockliffe 2014 7

8. V Lunn-Rockliffe 2014 8

9. Overbreathing and disease
• Asthma 14 L/min (Bowler)
• Heart disease 15 L/min (Dimopoulou)
• Diabetes 15 L/min (Tantucci )
• Epilepsy 13 L/min (Esquivel)
• Panic disorder 12 L/min (Pain)
• Obstructive Sleep Apnea (OSA) 15 L/min (Radwan)
Normal breathing 4-6 L /min
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10. How ‘normals’ breathe today
Dr. Artour Rakhimov (www.NormalBreathing.com
Dr. Artour Rakhimov (www.NormalBreathing.com)
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What disturbs breathing?
• Stress
• Coughing, crying
• Over-heating
• Over-eating
• Poor diet (inflammatory)
• Illness, infection
• Slumped posture
• Mouth-breathing habit
• Wrong advice, faulty instruction

12. V Lunn-Rockliffe 2014 12

13. Overbreathing
V Lunn-Rockliffe © 2014 13

14. Mouth-breathing
Strong correlation with
• narrow facial structure
• crowded, crooked teeth
• open bite
• gingivitis, dental decay
• orofacial muscle dysfunction
• aberrant swallow
• TMD
• bruxism
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15. 15

16. Mouth-breathing / Airway problems
In children - directly linked to:
• asthma
• recurrent ear infections
• bedwetting
• snoring
• OSA
• ADHD
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17. Carbon dioxide
Roles:
• balances and regulates pH
• stabilises mast cells
• regulates breathing
• synthesis antibodies, hormones, enzymes
• calms nervous system
• smooth muscle dilator
• facilitates release of oxygen (Bohr effect)
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18. Overbreathing effects (1)
Physical / mechanical
• Dehydration: mucosal dryness
• Airway trauma: inflammation, edema
• Enlarged uvula, tonsils, adenoids
• Vibration, turbulence, snoring
• -ve pressure, suction, collapse
V Lunn-Rockliffe 2014 18

19. Overbreathing effects (2)
Physiological / biochemical
• mast cells leak histamine
• smooth muscle spasm
• tissue hypoxia (Bohr effect)
• adrenaline, cortisol increase
• sympathetic nervous system stimulated
• blood pH increases
• central apnea, hypopnea
• mixed apnea
• instability in central control
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20. Effects of low CO2 on the brain
40% reduction in O2 after 1-minute hyperventilation
MRI Scan: red = most O2 dark blue = least O2 Litchfield1999
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21. Revved up nervous system
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22. Symptoms of overbreathing
Neurovascular:
Central: disturbances of consciousness, faintness, dizziness, unsteadiness, impairment of
concentration and memory, feelings of unreality, "losing mind"
Peripheral: Paraesthesia, numbness, tingling and coldness of fingers, face and feet
Musculoskeletal:
diffuse or localised myalgia and arthralgia, tremors and coarse twitching movements, carpopedal
spasm and generalised tetany (infrequent)
Respiratory:
cough, chronic throat tickle, shortness of breath, atypical asthma, tightness in or about chest, sighing
respiration, excessive yawning
Cardiovascular:
palpitations, skipped beats, tachycardia, atypical chest pains, sharp precordial twinges, dull precordial
or lower costal ache, variable features of vasomotor instability
Gastrointestinal:
oral dryness, globus, dysphagia, left upper quadrant or epigastric distress, aerophagy, belching,
bloating, flatulence
Psychological:
anxiety, tension and apprehension, inappropriate pseudocalmness (hysterical subjects)
General:
nocturia, easy fatigability, generalised weakness, irritability and chronic exhaustion, frightening
dreams, sleep disturbances
Adapted from Breath Connection - Fried R. 1990
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23. Points of view
“Open-mouth posture”
• Restricted airway
• Mechanical dysfunction
• Orofacial developmental issues
“Mouth-breathing”
• All the above
• Physiological consequences
• Biochemical
• Multi-system dysfunction
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24. Mouth-breathing
IS OVERBREATHING
What drives overbreathing?
• Stress
• Inflammatory diet
• Habit
• Need
What fixes overbreathing?
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25. Breathing Retraining
Restoring a physiologically normal breathing pattern
• breathing at the correct rate and rhythm and volume
• with the correct use of the breathing muscles
• at rest, during activity, speech, sleep and sport
• retraining respiratory centre’s breathing ‘set point’
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26. Assessment – Observation (1)
• Feel
• Rhythm
• Route
• Nares flare
• Sound
• Lips and Tongue
• Location
• Posture
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27. Assessment (2)
• Respiration rate
• Heart rate
• ‘Comfort’/ ‘Control’ Pause
• ETCO2
• Nose-breathing tolerance time
• Symptom picture
• 3-day food diary
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28. Breathing retraining process (2)
Education
Exercises and strategies
Lifestyle recommendations
Review
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29. Goal of breathing program
Relief from Snoring and Sleep Apnea T. Graham; Illustrator © A Calvert 29

30. 30
Goal
To turn the dial back to normal

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Nine healthy breathing habits
1. Awareness
2. Nose-breathing
3. Upright posture
4. Regular breathing
5. Diaphragm breathing
6. 8-12 breaths per minute
7. Silent invisible breathing
8. Breathing control during speech and singing
9. Breathing well during exercise
Relief from Snoring and Sleep Apnea ©Tess Graham

32. 32
Efficacy
Before and after
• Breathing assessment
• Symptom Trackers
• Partner / parent observations
• Capnometry
• Sleep studies

33. Case Study
Age 14
100% mouth-breather
Upper chest
Audible breathing
RR 16
HR 83
CP 17 secs
NBT 11 secs
Sleep apnea
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34. Symptom Tracker
Symptoms Assessment 1 Assessment2 Assessment 3 Assessment 4
Day 2 Day 5 Day 14
Sleep apnea observed XXXX XX X
Heavy, irregular breathing in sleep XXXX XX XX --
Toilet visits overnight 1 1
Waking with gasp 2-3
Blocked nose XXXX X
Waking with dry mouth XXXX XX X
Restless legs XXX XX X
Breath holding in day, sighing, yawning XX
Short of breath – resting XX
Frequent urination XX
Poor concentration XX X X
Mouth-breathing - night XXXX XXX XX XX
Mouth-breathing – day XXXX XX
Total symptom score 39 16 8 2
% reduction symptoms 59% 79% 95% 34

35. Before After
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36. Before After
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37. What you can do
Assess
• breathing pattern
• posture
• symptoms
• drive to breath
• triggers
Triage
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38. 38
Triage
Category 1: awareness and nose-breathing practice
– mouth-breathing – habit, not need
– easily wear appliance
Category 2: refer to breathing educator
– mouth-breathing – need and habit
– mild-mod overbreathing and symptoms
– struggle to wear appliance
Category 3 : refer to (Buteyko-trained) breathing educator
– mouth-breathing entrenched
– chronic overbreathing, mod-severe symptoms
– co-morbidities
– struggle/ cannot wear appliance

39. Teaching basic skills
• Awareness, understanding
• Nose-breathing practice
• ‘Unfold’ posture
• Less sugar
• Sleep position
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V Lunn-Rockliffe © 2014

40. Nose-breathing chart
DATE 10
seconds 20
seconds 40
seconds 60
seconds 90
seconds 120
seconds NOSE
BREATHER
Example
1st
try
Example
2nd
try
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Resources
Relief from Snoring and Sleep Apnea
Penguin Aus; Amazon US
Breathing Exercise Instruction Audio
CD and MP3 versions – BreatheAbility.com
Practitioner Training
admin@BreatheAbility.com