Hadas Golan,M.S., CCC/SLP, BBE Buteyko Educator and Trainer, Speech-Language Pathologist, Voice Specialist Boston Medical Center Department of

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1 Hadas Golan,M.S., CCC/SLP, BBE Buteyko Educator and Trainer, Speech-Language Pathologist, Voice Specialist Boston Medical Center Department of Otolaryngology Center for Voice and Swallowing

2 My name is Hadas Golan, and I will discuss the Buteyko principles in the treatment of dysphonia. I am a speech-language pathologist and a voice specialist at Boston Medical Center. I am also a member of the Buteyko Breathing Educators Association (BBEA) and the Training Institute of Buteyko Educators (TIBE). The information I'm presenting today is part of the Buteyko method. I do benefit financially from teaching the Buteyko program and training educators. I do not receive compensation for my roles at the BBEA and the TIBE. 2

3 For this is a great secret: all the healing forces reside originally in the human breathing system. anyone who truly understands the whole dimension of the breath knows the healing forces from the human side Rudolf Steiner ( ) All chronic pain, suffering and diseases are caused from a lack of oxygen at the cell level." Prof. A.C. Guyton, MD, The Textbook of Medical Physiology* 3

4 Buteyko history & clinical trials How does it work? Asthma PVFM Stress Dysphonia Facial development How to start normalizing the breathing today 4

5 Dr. Konstantin Buteyko was born in 1923 in Ivanitsa (near Kiev) As a medical student he was assigned to monitor the breathing of diseased patients He noticed that illness and deep breathing are correlated Dr. Buteyko developed a breathing program to correct dysfunctional breathing and restore health 5

6 Breathing exercises specially designed to restore normal breathing patterns combined with principles about physical exercise, food and sleeping as they relate to healthy breathing habits. Buteyko provides a safe, simple, and natural means of reducing the symptoms of asthma, allergies, chronic bronchitis, emphysema, sleep apnea, hyperventilation syndrome, panic attacks, bronchiectasis, hay fever, chronic sinusitis, rhinitis, and other stress-related diseases. 6

7 The Buteyko Method was developed in the 1950 s. It underwent extensive research and was finally implemented into widespread use by the medical community in Russia in the 80 s. The Buteyko Method is used widely in Russia, Australia, New Zealand, and Great Britain. It is taught in the U.S. since 1998 May the updated British Guidelines for the Management of Asthma endorsed Buteyko Technique so that GPs and asthma nurses can now recommend it. 7

8 At 12 weeks, BBT: 70% less symptoms 90% less need for reliever medication 49% less need for ICS Lung function- no change Control group- taught physiotherapy No change Bowler, Green and Mitchell MJA 1998; 169:

9 Results at six months; Buteyko Group Beta agonist decrease 85% ICS decrease 50% Control Group Beta agonist decrease 37% ICS no change NZMJ 12 December 2003, Vol 116 No

10 Improved asthma control from 41% to 75% 39% reduction of inhaled corticosteroids 100% elimination of inhaled corticosteroids by 21% of subjects " I've been astonished and also very pleased with the excellent result. There is no disruption of their life at all by their disease: normal activities; not waking at night; not needing to use any reliever medications. It's just great...75% control is about as good as anyone has got in any study of asthma. The neat thing about it is that it has no side effects. It's very safe. The Buteyko technique certainly has been shown to be an important adjunct to treatment." Cowie RL, Conley DP, Underwood MF, Reader PG, Respiratory Journal, 2008 May;102(5):

11 Breathing directly regulates body chemistry Including ph, electrolyte balance, blood flow, hemoglobin chemistry, kidney function, and delivery of oxygen and nitric oxide 11

12 Good breathing behavior means proper regulation of body chemistry that ensures proper distribution of oxygen Bad breathing behavior means deregulating body chemistry The effects of deregulated chemistry on health and performance can be dramatic and profound causing serious physiological crisis involving system-wide compromises 12

13 First Assignment Observe how many breaths you take in one minute 13

14 Gentle regular wave pattern 4-5 liters of air per minute with about 500ml each breath 8-10 breaths per minute Breathing through the nose Using diaphragm No upper chest movement Initiated at 40 mm Hg of CO2 in the arteries (PaCO2) 14

15 Anything that happens to the human body that the system wants to resist or reject sets up a stress response All stressors cause the same response in the body. (Mini) Fight or Flight reaction causes the release of adrenalin from the adrenal glands and our breathing rate rises 15

16 Fight or flight response 16

17 Hyperventilation Dr. Buteyko considered the 'Disease of Deep Breathing' to be the root cause of many health conditions Hyperventilation simply means breathing more than metabolism requirements He recognized chronic low grade over-breathing (hyperventilation) that goes unnoticed most of the time The Buteyko breathing method is designed to normalize ventilation minute volume to normal levels, leading to improvement of symptoms 17

18 Hyperventilation Da Costa, L.C Lum, Magarian describe the Hyperventilation Syndrome- a collection of bizarre, apparently unrelated symptoms at any organ or system This is a profound biochemical disturbance. Patients labeled with anxiety and implication that they are inadequate Symptoms can be reproduced by voluntary hyperventilation Hyperventilation Syndrome: A Diagnosis Begging for Recognition; GREGORY J. MAGARIAN, MD; DEBORAH A. MIDDAUGH, MD, and DOUGLAS H. LINZ, MD, Portland; Topics in Primary Care Medicine HYPERVENTILATION: THE TIP AND THE ICEBERG; L. C. Lum* Journal of Psychosomatic Research, Vol. 19, pp. 375 to 383. Pergamon Press, Printed in Great Britain 18

19 Chronic Hyperventilation is subtle Litres of air breathed per minute when resting: 12 x 0.5 = 6 (Normal) 20 x 0.5 = 10 Add effort: 20 x.75 = 15 Unrecognised because of the lack of obvious overbreathing and minimal discussion in medical school and textbooks 19

20 12 breaths per minute of 0.5 litre of air equals: 20 breaths per minute of 0.5 litre of air equals: 6 litres of air breathed each minute 360 litres per hour 8,640 litres per day 60,480 litres per week. 720 breaths per hour 17,280 breaths per day 120,960 breaths per week 10 litres of air breathed each minute 600 litres per hour 14,400 litres per day 100,800 litres per week breaths per hour 28,800 breaths per day 201,600 breaths per week 20

21 Recognize chronic hyperventilation: Mouth Open Hearing breathing during rest Sigh regularly Sniff Taking large breaths prior to talking Yawning with big breaths Upper chest movement Lots of visible movement 21

22 Normal breathing minute volume is 4-6 litres (W.H.O.) Minute Volume for asthma -14.1, 12, 15 litres. (Bowler, McFadden, Johnson) 1. Loss of CO 2? 2. Cooling of airways? 3. Drying of the airways? 22

23 "Noisy and deep" breathing of an asthmatic had always been considered an outcome of the disease. Nobody could even suspect that "deep breathing" was the cause of bronchial asthma, and increased depth of breathing could provoke the appearance of the symptoms of the disease. K P Buteyko MD 23

24 Breathing too much air maintains the normal pressure of oxygen, but it lowers carbon dioxide in both the lungs and the bloodstream 24

25 Is based on the importance of CO 2 in many of the functions of the body, including: Triggering the breathing mechanism Maintaining the correct ph (acidity or alkalinity) Smooth muscle function Low levels constrict, high levels relax Smooth muscle constricts at 30 mm Hg PaCO 2 Affecting airway, blood vessels, and guts 25

26 Traditional common sense has misguided us into believing that CO2 is poisonous. Proper exhalation of CO2 at rest~ 12-15% of the total CO2 arriving in the lungs The remaining 85-88% of the CO2 is retained in the blood, and is absolutely vital to ph regulation. Exhalation of more than this results in a CO2 deficit in the blood and other body fluidshypocapnia. Hypocapnia disrupts fundamental biochemistry. 26

27 Chemical receptors monitor CO 2 levels in the blood. They keep these levels normal. The receptors reset to trigger breathing at a lower level through constant exposure to CO2 levels lower than 40mm Hg Breathing is activated far earlier, causing overbreathing If over-breathing continues, the receptors continue resetting to lower and lower levels 41 mm Hg PaCO 2 Breathing increases up to an extra 3 LPM 40 mm Hg PaCO 2 Normal levels 33 mm Hg PaCO 2 Asthma symptoms 30 mm Hg PaCO 2 Asthma attack 27

28 Buteyko reverses the process by changing the level those chemo-receptors trigger The breathing exercises slowly get the body to adapt to trigger at higher levels of CO2 By reversing the process and sending messages of increased CO2 levels, it is possible to reset the trigger and return the breathing pattern to normal The result is breathing less air per minute 28

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33 As your ph goes higher than 7.45 Hemoglobin (oxygen- carrying blood cells) form a tighter bond with oxygen. (Bohr effect) Less oxygen is released to the tissues. Tissues begin anaerobic respiration, creating lactic acid and lowering the ph Kidneys extract bicarbonates to help lower ph 33

34 BAD DREAMS 34

35 What Does Asthma Look Like? 35

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37 When we feel stressed F&F is activated. Adrenaline revs up the body to survive a threat to life - a body that is pumped up and a mind that is hyper alert. Saves us from life threatening events. For some of us stress hormones wash through the body almost continuously 37

38 Present day chronic Fight or Flight Response Sighing, yawning, gasping, dry mouth, blocked nose, runny eyes Brain fog, irritability, anxiety, fear, lack of concentration, light-headed, dizziness High blood pressure, palpitations, cold hands and feet, headaches Poor digestion, constipation, IBS, flatulence Aching muscles, stiffness, fatigue 38

39 Rest and Digest Response We have another choice When activated heart rate drops, blood pressure falls, respiration slows down, blood flow to the core of the body is re-established improving digestion, immune system function, sense of well being Breathing is the easiest way to activate the R&D system This should be our normal mode and F&F for emergencies 39

40 Dr. Buteyko perceived it as another defense mechanism against hyperventilation Symptoms are very similar to hyperventilation syndrome: can t take deep enough breath, SOB, dizziness, lightheadedness, numbness, tingling, chest/throat tightness/pain, throat clearing, cough, asthma meds don t help Use current protocols through a Buteyko filter 40

41 CONSENSUS: Proper management of breath is essential to good singing production and vocal health There is no agreement in re the best approaches and techniques to achieve this. The vast majority of injured singers present in clinic employing excessive respiratory effort Excessive respiratory effort can manifest as both cause and effect in a disordered voice. The vast majority of injured singers say that they are trying to use more support 41

42 Typical pattern of topping off the tank! Tidal Breathing Normal Speech Breathing Resting Expiratory Level Lung Volume Time Typical pattern of speaking too long on one breath! Residual Volume 42

43 Subglottal pressure determined by the degree of expiratory muscles contraction on the resistance against airflow provided by the glottis The extent to which the vocal folds close, and the length of time they remain closed will influence subglottal pressure Directly related to Loudness 43

44 Breath mileage - how you valve the breath at the level of the glottis is as important (or more) than the size of the breath you take Sundberg: A minimum airflow is often considered a quality criterion for good singing- the less air consumption, the more skilled the singer Constant glottal leakage is a sign of poor voice technique 44

45 For the face and consequently teeth to develop correctly: Mouth closed with lips gently together; Three quarters of the tongue resting in the roof of the mouth, with the tip of the tongue placed behind the front teeth; Breathing through the nose; Correct swallowing; 45

46 Children whose mouth breathing is untreated may develop long, narrow faces, narrow mouths, high palatal vaults, dental malocclusion, gummy smiles, and many other unattractive facial features, such as skeletal Class II or Class III facial profiles. These children do not sleep well at night due to obstructed airways; this lack of sleep can adversely affect their growth and academic performance. Many of these children are misdiagnosed with attention deficit disorder (ADD) and hyperactivity General dentist: Mouth breathing: adverse effects on facial growth, health, academics and behaviour. Jefferson Y, 2010 Jan- Feb; 58 (1):

47 If mouth breathing is treated early, its negative effect on facial and dental development and the medical and social problems associated with it can be reduced or averted. General dentist: Mouth breathing: adverse effects on facial growth, health, academics and behaviour. Jefferson Y, 2010 Jan- Feb; 58 (1):

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49 Facial Characteristics 49

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51 Face and Jaw Development 51

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53 Buteyko therapy is a simple education program aimed at reversing chronic (hidden) hyperventilation The therapy compliments and improves conventional respiratory management Benefits of the treatment manifest initially as a reduction in symptoms and therefore a reduction in the need for medications/machines Buteyko is SAFE and EFFECTIVE 53

54 Improved asthma control and considerably less symptoms Considerably less allergic reactions in the airways, skin and gut, less mucus and congestion Dramatic reduction in medication Improved performance in sport and exercise Improved stress management and stress- related symptoms A good night's sleep Better voice Muscle relaxation 54

55 The fastest and best way to retain your CO 2 is to BREATHE ONLY THROUGH YOUR NOSE! This means ALL THE TIME! Day and Night During Exercise In fact, you should breathe through your mouth only as often as you eat through your nose! 55

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57 Hadas Golan Phone: Website: 57

58 Backup Slides 58

59 Fight for Flight kicks in when we take a breath through our mouths It triggers the sympathetic nervous system to activate quicken heart rate, faster breathing, pale, etc. 59

60 Minimizes hyperventilation of speech Decreases gasping and anxious presentation Improves dry throat and mouth and laryngeal irritation Decreases effort of breathing and speech Decreases vocal fatigue Improves sense of control Reduces upper chest involvement Allows the speaker to re-center and gives processing time for the listeners 60

61 Count to 50 breathing every 5 numbers When you need to breathe close your lips first Pause and allow the air to come in without sucking it in (take your time) Continue Practice reading the Rainbow passage 61

62 When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. ^ The rainbow is a division of white light into many beautiful colors. ^ These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. ^ There is, according to legend, a boiling pot of gold at one end. ^ People look, but no one ever finds it. ^ When a man looks for something beyond his reach, his friends say he is looking for the pot of gold at the end of the rainbow. 62

63 Breath Retraining Faulty breathing patterns are characteristic of people with respiratory disorders The aim is to achieve physiologically normal breathing- to retrain/reprogram the respiratory center Normalize each aspect of breathing (rate, rhythm, volume, mechanics), for all situations (awake, asleep, at rest, during exercise, during eating, and speech) Breathing is retrainable- habits can be changed 63

64 Breath Retraining First step is developing awareness to poor breathing habits- pay attention to breathing in different daily situations: how often do you breathe from your mouth, clear your throat, sigh, yawn, sniff, cough, breath hold, gasp when talking? Work towards a full-time nose breathing Work on relaxed, lengthened, upright posture Teach diaphragmatic breathing Work on breathing control during speech and exercise 64

65 Diaphragmatic Breathing Means drawing air in predominantly through diaphragm movement The size of the breath is appropriate for the situation Is often associated with a deliberate increase in breath size and filling more of the lungs 65

66 Diaphragmatic Breathing Normal tidal volume is 500 ml. Lungs have capacity for over 4000 ml Compared to breathing full lung capacity, normal resting breathing is small-volume diaphragm breathing Deep (full capacity) breath is only appropriate for vigorous physical exercise In common practice, deep or abdominal breathing exercises are large-volume diaphragmatic breathing 66

67 Breath Retraining Allow the exhale to occur on its own accord, without assistance from other muscles Allow for transition time between the exhale and the inhale Experience brainstem respiratory reflexes during transition time Breathe quietly, making the inhale satisfying and comfortable 67

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69 When normalizing CO2 - no need for protective mechanism of narrowing nasal passages Fewer irritants inhaled Excessive histamine production reduced resulting in less inflammation and mucus production By breathing less protective mucus does not dry out The immune system is working more efficiently 69